Citation Nr: 22014138 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 16-30 287 DATE: March 11, 2022 ORDER Service connection for residuals of a right wrist injury is denied. FINDING OF FACT The weight of competent, credible, and probative evidence does not support that the Veteran's residuals of right wrist injury manifested during service or to a compensable degree and continually from the Veteran's separation from service or was caused by any aspect of service. CONCLUSION OF LAW The criteria for service connection for residuals of a right wrist injury have not been met. 38 U.S.C. § 1101, 1110, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty in the United States Army from April 1966 to April 1968 including service in the Republic of Vietnam. This case comes before the Board of Veterans' Appeals (Board) on appeal of a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified before the undersigned Veterans Law Judge. The Veteran's claims file contains a copy of the hearing transcript. In August 2021, this issue was remanded for additional evidentiary development. The RO has substantially complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). SERVICE CONNECTION The Veteran contends that residuals of a right wrist injury were incurred in, aggravated by, or otherwise attributable to, active duty. At the Board hearing, the Veteran stated that a chain at the back of a truck caught his right wrist as it came down and caused extensive injury to the right wrist with residual symptoms and loss of function since that time. See October 24, 2018, Hearing Transcript, p. 3. In order to establish service connection on a direct basis, the record must contain competent evidence of: (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. Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). In the absence of proof of a present disability there can be no valid claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Competent lay evidence may also include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). 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 veteran prevailing in either event, or whether the weight 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. Certain chronic diseases, degenerative arthritis, will be presumed caused by service if they were shown as chronic in service (or within a presumptive period) and there are subsequent manifestations of the same chronic diseases; or if they manifested to a compensable degree within a presumptive period following separation from service (in this case, one year); or if they were noted in service, with continuity of symptomatology since service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Evidence and Analysis Personnel records show that the Veteran served as a radio relay operator including service in a signal battalion in Republic of Vietnam from April 1967 to April 1968. In an April 1968 separation report of medical history, the Veteran indicated that he had not had, and did not have swollen or painful joints; a history of broken bones; arthritis, bursitis, or rheumatism; joint or other deformity. He denied ever having an injury or illness other than those already reported. The only history reported were checked boxes for mumps, hay fever, and venereal disease. The Veteran denied any operations or self-treatment. In the separation report of medical examination, a clinician indicated all of that all of the Veteran's bodily systems were normal. The clinician did not report any additional physical abnormalities. A review of other service treatment records (STRs) reveals no complaints of. treatment for, or a diagnosis of, residuals of a right wrist injury. The Veteran was treated in Vietnam for venereal disease. In June 2000, a VA physician reported that the Veteran reported that his wrist pain had returned. The physician opined that the Veteran was happy with the results of the medication that had been prescribed to treat his overall musculoskeletal system pain. March 2013 inpatient records from C.C. hospital, a private facility, mention that the Veteran suffered from right wrist symptoms. Upon review of the May 2013 treatment records of Dr. W., the private physician in a specialized hand treatment practice indicated that the Veteran had a scapholunate advanced collapse (SLAC) wrist secondary to a jamming injury that occurred in June 2000. A year or two later (2002 or 2002), the Veteran had a spider plate put on as a SLAC wrist fusion was performed. Upon contemporaneous x-ray imaging of the Veteran's right wrist, a spider plate and broken-off screws were visible; both were impinging on the radius. Dr. W. interpreted that there could be "some remnant cartilage," on which the Veteran could maintain right wrist function if the spider plate and screws were removed. However, a right wrist fusion might be required at a later date. Subsequent records reveal that Dr. W. performed the recommended surgical procedure in June 2013. Upon review of VA treatment records and progress notes, VA clinicians noted that Dr. W. had performed surgery on the Veteran's right wrist in 2013. In subsequent records, the Veteran reported additional right wrist surgeries. And, in September 2013, Dr. W., performed a surgical procedure to excise a right wrist ulnar sling mechanism and "graphite-like material" in the Veteran's right wrist. Dr. W. also performed a right wrist capsuloplasty and right wrist arthroplasty at this time. In October 2013, Dr. W. reported that the Veteran's surgical wound was a little red, several days ago, but this has cleared. There was no evidence of infection. Moreover, Dr. W. wrote that the Veteran rotated his right easily and completely with supination and pronation, adding that the Veteran now moved his right wrist nicely. In a September 2014 lay statement, the Veteran reported that slipped while loading a tailgate in 1967 while stationed in the Republic of Vietnam. A chain at the back of this tailgate truck caught his right wrist as it came down and caused extensive injury to the right wrist. The Veteran reported that a medic wrapped his right wrist after the injury. Moreover, the Veteran wrote that throughout the years, his right wrist "became very, very" painful and required surgery in 1999 or early-2000. The Veteran reiterated that he had sustained a right wrist injury, associated with a truck tailgate, during service in his June 2016 substantive appeal (VA Form 9). In February 2018, Dr. W.'s records disclose that the Veteran underwent neurolysis and tenolysis procedures to alleviate carpal tunnel syndrome of the right hand. At the October 2018 Board hearing, the Veteran testified that a "day or two [after sustaining a right wrist injury] a Philippine medical team [] looked at my wrist and re-taped it, didn't take any x-rays or anything, and I was told to ice it up, and [] rest a bit." See October 24, 2018, Hearing Transcript, p. 3. In February 2020, the Veteran was afforded a VA wrist conditions examination. A VA clinician reviewed the Veteran's claims file; considered the Veteran's subjective accounts of his medical history; and conducted an in-person evaluation. This clinician provided present diagnoses of right wrist status post 2013 arthroplasty (total/ulnar replacement) and right wrist degenerative arthritis. This clinician summarized the Veteran's extensive courses of medical treatment. The clinician also performed an extensive inventory of right wrist clinical testing. The clinician included an extensive summary of the Veteran's lay statements of his medical history. Specifically, the Veteran reported that a tailgate dropped on his right wrist in 1967 when he was in the field. Upon returning from the field, the Veteran iced and taped his wrist. Also, the Veteran reported that he did not seek care until the 1990s when he his right wrist became painful. The Veteran added that upon x-ray imaging, he "was told" that he needed to have screws inserted; he the underwent surgery that prevented him from working for a few days. The Veteran did resume work, albeit with a case, in one week. After this, the Veteran indicated that he started to experience pain and, in turn, consulted Dr. W., as articulated above. The Veteran then underwent a "repeat surgery" to remove some screws in 2013, which brought some relief but, over time, there was a reoccurrence of pain. A couple of years the Veteran sought care with Dr. W., who wanted to immobilize the Veteran's right wrist. The Veteran declined the immobilization procedure. The Veteran's last treatment occurred two-and-a-half years earlier. The Veteran indicated that he had not sustained any additional symptoms. At the time of the evaluation of February 2020, the Veteran reported daily chronic right wrist pain which any movement aggravates. Rest and Tylenol provide relied within a few hours; however, the Veteran reported that he continued to use his left hand and wears a right wrist splint at all times to immobilize his right wrist. The clinician opined that the Veteran's present right wrist diagnosed disorders, as noted above, were less likely than not incurred in or caused by the Veteran's reported in-service right wrist injury. The clinician first explained that there is no evidence of a right wrist injury in the Veteran's STRs. Moreover, as already discussed, the Veteran denied swollen or painful joints; a history of broken bones; arthritis, bursitis, or rheumatism; joint or other deformity upon his April 1968 separation report of medical history. The clinician noted that the first VA notation of orthopedic complaints and treatment (progressive polyarthralgia) date from 2000. In 2000, the Veteran did not report that he had sustained a right wrist injury during active duty. The clinician also explained that the service connection claim was filed more than 4 decades after his separation. As noted above, this clinician included the Veteran's lengthy lay accounts of the trajectory of his right wrist injury, which underscores the tailgate right wrist injury in 1967, immediate icing and tapping, and subsequent care in the 1990sthat is, over 20 years after the 1967 injury. In July 2021, the Veteran submitted a color photograph which depicts two clinicians in surgical scrubs holding a bloodied hand. In an appended page, presumably the Veteran wrote, "Dr. Who checked my arm Jan 1968 after this surgery (Bone separation?)." In a November 2021, VA received private treatment records from HC, a private hand treatment facility. Upon review of these records, CD, a physician's assistant, reported the Veteran's account of the 1967 right wrist injury in service. Additionally, CD wrote that the Veteran reported that he was told upon evaluation when he returned from service that two bones had separated. In another account, CD wrote that the Veteran "got a destroyed wrist back from 1967 in [a] Vietnam War injury." Otherwise, these records show the Veteran's right wrist course of surgical interventions, therapies, and x-ray studies in 2020 and 2021. CD did not indicate whether he had reviewed the Veteran's STRs and medical history from 1967 to the 1990s. Thus, these records reference no medical documentation of the separated bones or "destroyed wrist". In November 2021, a VA clinician provided an opinion, in which the clinician carefully referenced all of the lay and the medical evidence of recordto include the evidence discussed above and the post remand reports of HC. Upon review of the entire file evidence, this clinician rendered a negative nexus opinion (that it is less likely as not that the Veteran's claimed residuals of a right wrist injury (or analogous disease entity), if any, were incurred in, caused or aggravated by service. The clinician provided an evidence-infused rationale to support the negative nexus opinion. The clinician wrote that, Based on review of additional information submitted since the Veteran's [February 2000 VA] examination, the right wrist condition is clearly related to a jamming injury that occurred in 2000, as documented by Dr. W. in his note on May 14, 2013. Injury with TX with a spider plate in 2002 as a SLAC wrist fusion, screws and plate were later removed in 2013 due to impingement. There is no mention of a prior service injury at [in] the initial note with Dr. W. [M]ore recent notes report that a wrist condition is due to traumatic injury in Vietnam as reported by the [Veteran] with no documentation in STRs and [an] unremarkable separation exam, making it unlikely related to service and more likely related to [the] injury in 2000. [In] initial VA PC notes on June 2000, [the Veteran] denied upper extremity (UE) trauma for [bilateral shoulders] and wrist pain. Then [the Veteran] resumed care at VA [in] February 2014. There [are] conflicting reports from [the Veteran], but medical documentation supports [that the right] wrist condition [is] secondary to injury in 2000, that has required multiple surgeries, with the most recent being a wrist fusion on June 8, 2020. There is no evidence to support that [the Veteran's] right wrist condition was incurred, caused or aggravated during active duty [from April 1966 to April 1968. The Board may favor the opinion of one competent medical examiner over that of another as long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). An evaluation of the probative value of medical opinion evidence is based on the medical expert's examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. See Guerrieri v. Brown, 7 Vet. App. 467 (1993). Greater weight may be placed on one practitioner's opinion over another depending on factors such as reasoning employed and whether or not and the extent to which they reviewed prior clinical records and evidence. See Gabrielson v. Brown, 7 Vet. App. 36 (1994). Furthermore, the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar v. Brown, 5 Vet. App, 140 (2003). Unlike CD (and his reports of an in-service injury that "destroyed" the Veteran's right wrist), the November 2021 VA clinician reviewed the entirety of the claims file and considered the Veteran's various lay accounts of his medical history. This expert did not provide conclusory findings without reference to evidence of record. And, this clinician provided an extensive rationale to support her negative nexus opinion. The clinician "rooted" the Veteran's right wrist surgery to the May 2013 treatment records of Dr. W., who indicated that the Veteran had a scapholunate advanced collapse (SLAC) wrist secondary to a jamming injury that occurred in June 2000. A year or two later (2002 or 2002), the Veteran had a spider plate put on as a SLAC wrist fusion was performed. Consequently, the November 2021 VA clinician's opinion warrants far greater probative weight that the conclusory etiological conclusion offered by CD. Owens, 7 Vet. App. 429; Guerrieri, 7 Vet. App. 467; Gabrielson, 7 Vet. App. 36; Sklar, 5 Vet. App, 140. The Veteran believes that his present "residuals" of a right wrist injury were caused by an in-service injury. Indeed, the Veteran is competent to report discernable symptoms like wrist pain. Jandreau, 492 F. 3d 1372; Kahana, 24 Vet. App. 428). However, the record fails to disclose that the Veteran has training or expertise in hand surgery or orthopedics, as such the Veteran's lay contentions do not constitute competent medical evidence of any right wrist condition's etiology or causation. 38 C.F.R. § 3.159(a)(1). Moreover, the Veteran's lay accounts warrant low credible weight because they have been inconsistent, from "slipping while loading a tailgate in 1967 while stationed in the Republic of Vietnam" to the "commencement of right wrist treatment in the 1990s" and accounts of bone separation at the end of active-duty service. Even if the Veteran's right wrist was struck by a tailgate, the weight of evidence is that an injury, if any, did not require more treatment than reported by the Veteran as wrapped, iced, and rested. The Board places low weight on the report of an injury in service as severe as shown in the photograph, that was not noted in the service treatment records and denied by the Veteran at the time of discharge. The Board also places very low credible weight on the report of continuity of residuals from that reported injury for the same reasons. These lay accounts have not been internally consistent or consistent with the medical evidence of record and the Veteran denied any injury or treatment in his discharge examination when there was an opportunity to do so in an examination specifically performed to identify any abnormalities caused by service. As such the Board finds that the Veteran has not been a either a consistent or candid historian and is therefore not credible. Caluza, 7 Vet. App. 498; Barr, 21 Vet. App. 303. The current disability prong of a right wrist condition is present. However, the weight of lay and medical evidence fails to establish an in-service incurrence or predicate upon which a nexus can be drawn; with this element, service connection cannot be established. Saunders, 886 F. 3d 1356. In sum, the weight of probative evidence is against the Veteran's service connection claim. As such, there is no doubt to be resolved. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.