Citation Nr: 22011954 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 16-27 944 DATE: March 2, 2022 ORDER Entitlement to service connection for a right wrist disability is denied. FINDING OF FACT A fracture of the right ulnar styloid process is shown to have pre-existed service, is shown to have been noted upon entry to service, and is shown not to have increased in severity during active service. CONCLUSION OF LAW The criteria for entitlement to service connection for a right wrist disability have not been met. 38 U.S.C. §§ 1110, 1117; 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1991 to October 2007. He had service in Southwest Asia from February 2002 to February 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision. The issue remaining on appeal was remanded for additional development in January 2019 and June 2021. Service Connection Claim Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a). Generally, the evidence must show: (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, 1166-67 (Fed. Cir. 2004). The term "disability" for VA compensation purposes refers to the functional impairment of earning capacity rather than the underlying cause of the impairment and it is noted that pain alone may be a functional impairment. See Saunders v. Wilkie, 887 F.3d 1356, 1364-68 (Fed. Cir. 2018). Applicable VA regulations provide that a Veteran is presumed to be in sound condition when examined, accepted, and enrolled for service, except for defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence (obvious or manifest) demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). History of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. Determinations should not be based on medical judgment alone as distinguished from accepted medical principles, or on history alone without regard to clinical factors pertinent to the basic character, origin and development of such injury or disease. They should be based on thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to accepted medical principles pertaining to the history, manifestations, clinical course, and character of the particular injury or disease or residuals thereof. 38 C.F.R. § 3.304(b)(1). History conforming to accepted medical principles should be given due consideration, in conjunction with basic clinical data, and be accorded probative value consistent with accepted medical and evidentiary principles in relation to value consistent with accepted medical evidence relating to incurrence, symptoms and course of the injury or disease, including official and other records made prior to, during or subsequent to service, together with all other lay and medical evidence concerning the inception, development and manifestations of the particular condition will be taken into full account. 38 C.F.R. § 3.304(b)(2). Signed statements of veterans relating to the origin, or incurrence of any disease or injury made in service if against his or her own interest is of no force and effect if other data do not establish the fact. Other evidence will be considered as though such statement were not of record. 38 C.F.R. § 3.304(b)(3). When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has also clarified that when "a later medical opinion is based on statements made by the veteran about the preservice history of his condition, contemporaneous clinical evidence and recorded history may not be necessary." Harris v. West, 203 F.3d 1347, 1351 (Fed. Cir. 2000). In Doran v. Brown, 6 Vet. App. 283, 286 (1994), the U. S. Court of Appeals for Veterans Claims concluded "as a matter of law, that the presumption of soundness was rebutted by clear and unmistakable evidence consisting of [the] appellant's own admissions . . . of a preservice [disability]." A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during that active service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. VA regulations also provide that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses to a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability if that disability became manifest either during active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2026, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstrations of laboratory abnormalities. Chronic multisymptom illness of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue, (2) Signs or symptoms involving skin, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurologic signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the respiratory system (upper or lower), (9) Sleep disturbances, (10) Gastrointestinal signs or symptoms, (11) Cardiovascular signs or symptoms, (12) Abnormal weight loss, and (13) Menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 (Aug. 3, 1998). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another, provided an adequate basis is provided. Owens v. Brown, 7 Vet. App. 429 (1995). In determining whether evidence submitted by a claimant is credible, VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). A medical opinion based upon an inaccurate factual premise may be discounted entirely. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102. The Veteran contends that he has a right wrist disability as a result of active service. Recognizing that he had injured his wrist prior to service, he asserts that he re-injured his right wrist during active service. Service treatment records show that upon enlistment examination the Veteran reported a history of having broken his right wrist at age 15. No underlying disability was noted, however. An August 2003 report noted he complained of right wrist pain with no known trauma. The assessment was possible sprain. A September 2007 treatment report noted the Veteran complained of right wrist pain after punching a heavy bag while working out. He denied prior treatment. An X-ray study revealed an old injury to the right ulnar styloid. A diagnosis of acute right wrist sprain. VA examination in November 2007 included a diagnosis of chondromalacia right wrist status post trauma with objective evidence of residual painful and decreased range of motion. It was noted the Veteran reported having constant pain since training with a heavy bag in September 2007. He reported that an X-ray study at that time revealed a bone chip. The examiner noted decreased motion without evidence of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement. A November 2007 X-ray examination revealed accessory ossicles to the ulnar carpal joint with no significant degenerative disease or alignment of the osseous structures. VA treatment records include a June 2008 report noting the Veteran had orthopedic system complaints of shoulder/wrist pains described as intermittent arthralgias. An examination of the extremities revealed no edema. The examiner's assessment included shoulder/wrist pains. An August 2012 private medical report noted the Veteran reported having hit a rock with his right wrist during a rough parachute landing in September 2004 and reinjuring the wrist during hand to hand combat training in 2007. He reported having had treatment with medications and light duty. He complained of progressive right wrist pain. The examiner noted decreased motion and markedly diminished grip strength. An X-ray showed a free bone fragment, which the examiner noted "answers random locking of the right wrist." A diagnosis of posttraumatic residual degenerative joint disease of the right wrist with neurological (motor) sequelae. The examiner found the disorder was more likely than not directly and causally related to the injury in service. VA examination in June 2013 included a diagnosis of history of a fracture right wrist. It was noted the Veteran had a history of a right wrist fracture at age 15 and that he reported having reinjured the wrist in 2004 and in 2007. He reported he chipped the wrist in the 2004 incident and that since then he experienced locking of the wrist, having to hold a pen and write differently, and having pain on activities requiring dexterity. Imaging studies did not document degenerative or traumatic arthritis nor other significant findings or results. The examiner noted decreased, painful right wrist motion but found it was less likely that the Veteran's right wrist fracture was permanently aggravated by service. The rationale for the opinion was that service treatment records were not indicative of recurrent/chronic or worsening right wrist complaints, treatment, or injury. VA examination in December 2019 included a diagnosis of right wrist fracture (which clearly and unmistakably existed prior to service). The examiner found the disorder clearly and unmistakably existed prior to service and was not aggravated beyond its natural progression by an in-service, event, injury, or illness. As rationale, it was noted the Veteran was treated for right wrist pain once while in service and that the issue resolved without complication and did not require any additional medical evaluation or treatment. It was further noted that the Veteran had broken his wrist at age 15 and that it had been treated by casting and that the bone healed. There was no documentation of reduced range of motion upon enlistment examination. The examiner found that the X-ray evidence did not confirm a fractured wrist and that the treatment in service for right wrist pain was shown to have resolved without complication. There was no objective evidence of a chronic disability. The current wrist condition was found to be not related to, caused by, or aggravated by his military service. VA examination in October 2021 included diagnoses of residuals of fracture, right ulnar styloid, and associated radiographic findings of three corticated bony fragments. It was noted the radiographic findings were incidental and of questionable clinical significance. The Veteran reported dull, achy pain with weather changes or overuse that was mild to moderate in severity. The examiner summarized the pertinent evidence of record. In a December 2021 report, the examiner found the Veteran's present right wrist disorder clearly and unmistakably existed prior to service and was not aggravated beyond its natural progression by an in-service event, injury, or illness. The Board recognizes that the examiner stated it was at least as likely as not that the right wrist condition pre-existed service. However, in his provided rationale, he explained that the Veteran's pre-existing fracture of the right ulnar styloid process (right wrist) clearly and unmistakably occurred at age 15 as shown by the enlistment examination and subsequent service treatment records. The examiner further noted that a review of radiographic studies of the right wrist indicated no other fractures prior to or after enlistment. The examiner stated that the pre-existing condition did not worsen or increase in severity during service and found that the right wrist sprain he experienced during active service was acute and isolated and resolved without residual. Support for the opinion was noted to the silence in the service treatment records for continued, chronic treatment. The examiner found the November 2007 VA examination diagnosis of chondromalacia of the right wrist was erroneous because the examiner did not have access to service treatment records for review and the diagnosis was based solely on the Veteran's statement of history that did not include his prior wrist fracture. The current condition was found to represent the present manifestation of the pre-existing condition based upon rationale that there was no radiographic evidence of degenerative changes of the right ulnar carpal joint. The examiner stated, however, that it would not be unexpected that after approximately 35 years some symptoms could manifest in the form of mild subjective pain. The three corticated bony densities noted on radiographic studies almost certainly had their onset at the time of the original fracture and are clinically insignificant. The examiner subsequently provided additional information for clarification noting that radiographic studies performed in December 2021 revealed degenerative changes in both wrist joints (radiocarpal joints) with "an old comminuted ulnar styloid fracture unchanged from 2013 with no progression of degenerative changes to the right wrist." The "3 corticated bony densities" noted in 2013 appeared to have resolved. The examiner found it was very unlikely that a right wrist sprain during active military service would ultimately result in bilateral wrist joint osteoarthritis. The more likely explanation was that the Veteran's current bilateral degenerative osteoarthritis of the wrist joints was due to normal and expected aging. The examiner concluded that the Veteran's original injury (pre-existing fracture of the right ulnar styloid process) clearly and unmistakably occurred at age 15 as per his enlistment examination and subsequent service treatment records. It was further found that his subsequent right wrist sprain due to working out on a heavy bag without proper taping was acute and isolated and resolved without residual as evidenced by the remainder of the Veteran's service treatment records. The examiner found that the Veteran's current symptoms of mild occasional right wrist stiffness, especially in the morning, were merely sequelae of the original fracture that occurred at age 15 and was not a separate condition. It was explained that this was not an undiagnosed illness was not a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. The examiner reiterated that the current symptoms were merely expected sequelae of the original fracture. As rationale, it was noted that some pain with vigorous activities may be expected for the first year, that some residual stiffness or ache was to be expected for two years or possibly permanently, especially for high-energy injuries, in patients older than 50 years of age, or in patients who have some osteoarthritis. Based upon the overall evidence of record, the Board finds that the Veteran's fracture of the right ulnar styloid process is shown to have pre-existed service. Recognition is given to the fact that a symptomatic disability of the right wrist was noted on entrance examination. However, given the history that the Veteran provided at the time of his enlistment, and the findings made by multiple VA examiners, there is clear and unmistakable evidence that a disability of the right wrist pre-existed service. There is no evidence that the disability increased in severity during active service. The December 2021 VA opinions are found to be persuasive and based upon adequate rationale. The evidence of record upon enlistment indicating a right wrist fracture at age 15 and the December 2021 VA examiner's opinion constitute notation of the preservice existence of a fracture of the right ulnar styloid process. The December 2021 examiner's determination as to this matter is shown to have been based on a thorough analysis of the evidentiary record and a careful correlation of all material facts, with due regard to accepted medical principles pertaining to the history, manifestations, clinical course, and character of the particular injury or residuals. The determination as to preservice existence is further found to be consistent with accepted medical evidence relating to incurrence, symptoms and course of the injury or disease, including official and other records made prior to, during or subsequent to service, together with all other lay and medical evidence concerning the inception, development and manifestations of the particular condition. The December 2021 VA examiner's opinion is also persuasive that the Veteran's pre-existing right wrist disability did not worsen or increase in severity during service. The examiner specifically found that the right wrist sprain he experienced during active service was acute and isolated and resolved without residual. The examiner is shown to have reviewed the evidence of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). To the extent the Veteran contends that he sustained a more severe re-injury to the right wrist than shown by the available service treatment reports with continued symptoms of pain after a 2004 parachute landing, the Board finds such contentions to be not credible due to inconsistency with other evidence. See Caluza, 7 Vet. App. 498. It is significant that he denied prior treatment in September 2007 and that the examiner's diagnosis at that time was acute right wrist sprain. There is no indication of a history of his having re-injured his right wrist in a parachute jump at his VA examination in November 2007. Nor did he indicate having had any continued symptoms of right wrist pain prior to September 2007. The record includes a November 2007 VA examination diagnosis of chondromalacia right wrist status post trauma with notation of constant pain since September 2007 and an August 2012 private medical diagnosis of posttraumatic residual degenerative joint disease of the right wrist that was more likely than not directly and causally related to an injury in service. However, the diagnoses and opinions are shown to have been provided based upon an erroneous report as to pertinent medical history. Neither examiner is shown to have been informed of the Veteran's preservice right wrist injury at age 15 nor to have reviewed any actual service treatment records. As such, these opinions are found to have been based upon an inaccurate factual premise and the opinions as to etiology are discounted entirely. See Monzingo, 26 Vet. App. 97. Consideration has also been given to the Veteran's personal assertion that he has a right wrist disability related to active service, including as due to aggravation of his preservice right wrist disability. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disability at issue is not a condition that is readily amenable to lay diagnosis or probative comment regarding etiology or aggravation. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board acknowledges that the Veteran is competent to report observable symptoms, but there is no indication that he is competent to etiologically link any such symptoms to a current diagnosis. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. The Board further find that the evidence demonstrates no signs or symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness in the right wrist associated with service in Southwest Asia. Such is simply not supported by the record. In conclusion, the Board finds that service connection for a right wrist disability is not warranted. The persuasive evidence is against the claim. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Douglas 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.