Citation Nr: 22017808 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 18-13 663 DATE: March 26, 2022 REMANDED Entitlement to service connection for a neck disability, to include as secondary to service-connected degenerative disease of the lumbar spine (low back disability) and/or acromioclavicular widening, status post remote surgery, left and right shoulders (bilateral shoulder disabilities), is remanded. Entitlement to service connection for a left wrist disability manifested by tingling and numbness, to include tenosynovitis, De Quervain's syndrome, cervical radiculopathy, cubital tunnel syndrome, and/or carpal tunnel syndrome, to include as secondary to a service-connected low back disability, bilateral shoulder disabilities, and/or to a non-service-connected neck disability, is remanded. Entitlement to service connection for a right wrist disability manifested by tingling and numbness, to include tenosynovitis, De Quervain's syndrome, cervical radiculopathy, cubital tunnel syndrome, and/or carpal tunnel syndrome, to include as secondary to a service-connected low back disability, bilateral shoulder disabilities, and/or a non-service-connected neck disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from May 1985 to August 2009. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In his March 2018 substantive appeal, the Veteran expressly limited his appeal to the issues addressed herein. As such, the Board will limit its consideration to those issues as well. In September 2021, the Veteran testified at a virtual Board before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. 1. Entitlement to service connection for a neck disability, to include as secondary to a service-connected low back disability and/or bilateral shoulder disabilities, is remanded. The Veteran contends that he has a neck disability was incurred in or caused by service. Specifically, at the September 2021 Board hearing, he contended that the disability was due to an accumulation of falls, work, and wear and tear during his service, but that the actual injury to the neck was not found until later. He also contended in his June 2015 application that his neck disability was secondary to his service-connected low back disability and/or bilateral shoulder disabilities. As an initial matter, the Board notes that post-service treatment records as early as October 2010 show that the Veteran had a diagnosis of cervicalgia. A February 2012 MRI (magnetic resonance imaging) of the lumbar spine showed central canal narrowing at L3-S1, narrowing of the neural foramen, positive thickening, and also noted that these problems were causing C6-7 (cervical) spinal cord compression. An MRI of the lumbar spine from June 2012 showed disc pathology from C4-C7 and thickening at C6-7, and again noted that this caused spinal cord compression. A May 2013 MRI of the cervical spine showed a new disc protrusion/extrusion at C3-4 causing cord compression, as well as moderate to severe spondylitic changes, with abnormal cord signal at the C5 level. A private treatment record from June 2013 demonstrates that the Veteran had been diagnosed with herniated cervical discs at that time and noted that he underwent an anterior cervical discectomy and fusion of C3-4 at that time. Given these findings, the Board finds that the first element of service connection, regarding the presence of a current disability, has been established. The Veteran is also currently service-connected for a low back disability and bilateral shoulder disabilities. The Veteran's service treatment records (STRs) show that he complained of and was treated for neck pain during service. A May 2005 STR shows that he reported pain in his neck at that time. A November 2007 STR shows that he was seen for back pain at that time, but examination of the cervical spine revealed tenderness to palpation of the spinous process and the transverse process. A January 2008 STR shows that he reported numbness and tingling in his arm as well as in his neck if he was hit on the shoulder, although a cervical screen was negative at that time. In April 2008 and July 2008, the Veteran again reported neck pain, but examination was again normal. Regarding the Veteran's contention that his neck disability is due to falls in service, the Board notes that his STRs show that he fell during service in September 1990, October 1991, July 1999, and October 1999, but that in each of these instances he fell on his wrist, hand, or shoulders, and that those STRs do not mention treatment for, complaints of, or any diagnosis related specifically to the neck. Regarding the nexus, or link, between the Veteran's current neck disability and his service, the Veteran submitted a statement from his private provider, G.B., F.N.P., in March 2018. Mr. B. noted that the Veteran retired from service in 2009, and that review of his record revealed only incidental neck concerns in January 2008 and on one other date that is not clearly defined in the statement. He further noted that imaging of the cervical spine was not obtained until January 2013, which revealed severe to moderate multilevel degenerative changes, and that a subsequent MRI revealed additional problems, including disc bulges with nerve contacts. Mr. B. also noted the June 2013 surgical intervention. He then stated that though no direct complaints of neck pain were made while the Veteran was on active duty, he was mostly seen for right shoulder pain and underwent surgical repair for that issue. He opined that the Veteran's neck pathology was extensive and that it was likely present during his time on active duty. He added that he was certain that the Veteran's shoulder injury was contributory to his cervical finding. While clearly supportive of the Veteran's claim, the Board finds Mr. B.'s March 2018 statement insufficient to support an award of service connection. His opinion that the Veteran's neck disability was likely present in service is not supported by sufficient rationale, and it is also not entirely consistent with the evidence of record, which shows that the Veteran directly reported neck pain during his service and that he was diagnosed with cervicalgia just over a year after his separation from service. His opinion that the Veteran's shoulder injury contributed to his neck disability is also not supported by any rationale. To date, the Veteran has not been afforded a VA examination in connection with his claim. Given the presence of a current diagnosis, in-service complaints of neck pain, the February 2012 and June 2012 MRIs indicating that problems in the lumbar spine might be causing the issues in the cervical spine, Mr. B.'s March 2018 statement indicating that the Veteran's neck disability is service-related, and the fact that the Veteran is currently service-connected for a low back disability and bilateral shoulder disabilities, the Board finds that a VA medical examination and/or opinion is warranted. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Updated records of any VA and service department treatment the Veteran has received should also be procured. Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency). 2. Entitlement to service connection for a left wrist disability manifested by tingling and numbness, to include tenosynovitis, De Quervain's syndrome, cervical radiculopathy, cubital tunnel syndrome, and/or carpal tunnel syndrome, to include as secondary to a service-connected low back disability and/or bilateral shoulder disabilities, is remanded. 3. Entitlement to service connection for a right wrist disability manifested by tingling and numbness, to include tenosynovitis, De Quervain's syndrome, cervical radiculopathy, cubital tunnel syndrome, and/or carpal tunnel syndrome, to include as secondary to a service-connected low back disability and/or bilateral shoulder disabilities, is remanded. The Veteran contends that he has disabilities of both wrists that are manifested by numbness and tingling that were incurred in or caused by service. At the September 2021 Board hearing, he contended that he fell on and was treated for injuries to both wrists during service. He contended that he had tingling during service, and that while testing did not find anything, he has had tingling since that has progressed. He also contends that his wrist disabilities are secondary to his service-connected low back and/or bilateral shoulder disabilities, and/or to his non-service-connected neck disability, testifying at the September 2021 hearing that a doctor had recently told him that the tingling was more likely related to his shoulders and his neck. For informational purposes, the Board notes that at the September 2021 hearing, the Veteran also testified that he had limited range of motion and swelling in his left wrist. The Board notes that the Veteran is already service-connected for degenerative disease in the left wrist, as well as degenerative disease in both hands. The Board thus understands that his current claims are for service connection for disabilities of the wrists that are separate and distinct from degenerative disease. Turning to the merits of the matter, the Board notes that a private February 2013 electromyography (EMG) showed bilateral carpal tunnel syndrome and bilateral cubital tunnel syndrome, and the interpreting provider noted that the Veteran had multiple compression neuropathy in both upper extremities. The Veteran had another EMG in November 2015, this time afforded by VA, which showed evidence of right multilevel cervical radiculopathy and right focal median mononeuropathy. A May 2013 VA treatment record noted neck and radicular pain. A September 2014 VA treatment record also shows that the Veteran reported chronic dorsal radial wrist pain since 1996 when he had an injury, and range of motion of both wrists was limited on examination. Radiographs showed evidence of advanced radial scaphoid arthritis, and he was diagnosed with osteoarthritis of the wrist. He was also given provisional diagnoses of tenosynovitis and De Quervain's syndrome. An April 2015 VA treatment record shows that tenosynovitis, De Quervain's syndrome, and cervical radiculopathy were all included in his active problem list. Given this evidence, the Board finds that there is clear evidence of current disabilities of both wrists that are separate and distinct from the Veteran's already service-connected bilateral hand and left wrist degenerative disease. The first element of service connection has therefore been established. The Veteran's STRs also confirm that the Veteran was treated for injuries to both wrists during service. A September 1990 STR shows that he fell on his left wrist during a flag football game. Examination showed significant edema, and he was diagnosed with a left wrist sprain. He was also given a physical profile at that time regarding the injury. A February 1997 STR shows he was again seen for left wrist pain when he was diagnosed with chronic scaphoid left wrist. A physical profile from March 1997 shows a diagnosis of chronic scaphoid lunate dislocation of the left wrist, and December 1997 STRs again note the injury and an additional physical profile. An October 1998 STR shows a history of left wrist pain from April 1996 to the present and indicates that the Veteran underwent physical therapy for 7 months. Surgery was advised, and the issue was noted as unresolved. A January 1999 STR shows that the Veteran still had intermittent left wrist pain, though he had resumed full activities by that time. A July 1999 STR shows that the Veteran fell onto his right hand and had persistent pain and swelling. He was given a rule out diagnosis of occult fracture and was given a physical profile as he had to wear a cast for two weeks. An October 1999 STR shows that the Veteran reported pain in his fingers, thumb weakness, and difficulty grasping objects, identified the problem as being in his wrist, described it as soreness, cramping, and 'pins and needles,' and noted that he first noticed it in 1995. In a December 2001 STR, the Veteran reported numbness in his hands for the previous 3 weeks, stating that it did not go away. He was diagnosed at that time with ulnar sensory neuropathy. In a January 2002 STR, he again reported numbness on and off to his left hand for the previous month. An October 2003 MRI of the left wrist showed that the joint was stable, but also showed a significant DISI deformity and a possible intra-articular body dorsal to the carpus. In an April 2006 post-deployment questionnaire, the Veteran reported that he had numbness and tingling in his hands or feet both during and after his deployment. In a June 2006 STR, a provider noted a history of left scaphoid dislocation and that the Veteran reported bilateral wrist pain. On examination, there was no numbness or tingling, but a Finkelstein's test on the right wrist indicated tenosynovitis, and he was diagnosed with joint pain localized in the wrists. The radiology report also noted a history of chronic scaphoid lunate dislocation in the left and right wrists. May 2007, April 2008, and July 2009 STRs show that problem lists included 'tingling' and joint pain in the wrists. Finally, a July 2009 STR shows that the Veteran was taking pain medications for pain in the shoulders, wrists, knees, and ankles. Turning to post-service records, the Board notes that the Veteran was afforded a general VA examination in July 2010, which included an examination of his left wrist. The examiner noted that the Veteran had problems with his left wrist and found that it was injured in 1994. He also noted that the right wrist was injured in 1994. On examination, there was an overall decrease in the strength and dexterity of the Veteran's hands, including locking. The examiner further indicated that there was a history of paresthesias in both hands, as well as a history of numbness in both hands. A November 2018 VA treatment record noted that the Veteran's hand pain was coincident with his neck pain and went into his fingers. The provider noted that the Veteran presented with cervical stenosis and symptoms, and that there was imaging evidence of bilateral cervical radiculopathies. While the Veteran was afforded a VA examination in April 2015 regarding his left wrist, it appears that that examination was related to his service-connected left wrist degenerative disease. To date, he has not been afforded a VA examination in connection with his claim for wrist disabilities manifested by tingling and numbness that are separate and distinct from his service-connected left wrist and hand degenerative disease. Given the evidence outlined above, the Board finds that a VA examination and/or medical opinion is warranted. See McLendon, supra. The matters are REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. Obtain copies of records pertaining to any additional, relevant treatment the Veteran has received at Quantico and Fort Belvoir since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. After the foregoing development has been completed to the extent possible, arrange to provide the record on appeal to an appropriate VA examiner for the purpose of assessing the etiology of the Veteran's neck disability. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has a disability of the neck that had its onset in, or is otherwise attributable to, service. In so doing, the examiner should consider and address the May 2005, November 2007, January 2008, April 2008, and July 2008 STRs showing that the Veteran reported or was treated for neck pain in service; the October 2010 private treatment record showing a diagnosis of cervicalgia just over a year after the Veteran's separation from service; and Mr. B.'s March 2018 statement that the Veteran's neck pathology was extensive and that it was likely present during his time on active duty. The examiner should also consider the Veteran's contention that falls, work, and wear and tear during service caused his neck disability. If the examiner finds that it is unlikely that the Veteran's neck disability was incurred in, or otherwise attributable to, service, he or she should offer a further opinion as to whether it is at least as likely as not that it was a) caused or b) aggravated (i.e., worsened beyond its natural progression) by his service-connected low back disability and/or bilateral shoulder disabilities. In so doing, the examiner should consider the February 2012 and June 2012 MRIs of the lumbar spine, both of which appear to indicate that problems in the lumbar spine, including narrowing of the foramen and thickening are "causing" cervical cord compression. He or she should also consider Mr. B.'s March 2018 statement that he is certain that that the Veteran's shoulder injury was contributory to his cervical finding. The need for an in-person examination and/or video or telephonic interview of the Veteran is left to the discretion of the examiner. A complete medical rationale for all opinions expressed must be provided. 4. Also arrange to provide the record on appeal to an appropriate VA clinician for the purpose of assessing the etiology of the Veteran's wrist disabilities that are manifested by tingling and numbness (other than degenerative disease), to include tenosynovitis, De Quervain's syndrome, cervical radiculopathy, cubital tunnel syndrome, and/or carpal tunnel syndrome. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that any of the Veteran's identified left or right wrist disabilities (other than degenerative disease) were incurred in, or are otherwise attributable to, service. In so doing, the examiner should consider the September 1990, February 1997, March 1997, December 1997, October 1998, January 1999, July 1999, October 1999, December 2001, January 2002, October 2003, April 2006, June 2006, Mary 2007, April 2008, and July 2009 STRs showing that the Veteran was treated and had physical profiles regarding problems with both wrists, to include tingling and/or numbness, during service. The examiner should also consider the July 2010 VA examination report in which the examiner indicated that the Veteran had a history of paresthesias and numbness in both hands. If the examiner finds that it is unlikely that the Veteran's wrist disabilities, manifested by tingling and numbness, had their onset in, or are otherwise attributable to, service, the examiner should also offer an opinion as to whether it is at least as likely as not that the Veteran's wrist disabilities were a) caused or b) aggravated by his service-connected low back disability and/or bilateral shoulder disabilities. If, and only if, it is determined that the Veteran's neck disability is service-connected, the examiner should offer a further opinion as to whether it is at least as likely as not that the Veteran's wrist disabilities were a) caused or b) aggravated by his neck disability. In so doing, the examiner should consider the November 2018 VA treatment record indicating that the Veteran's hand pain is coincident with his neck pain, and that imaging evidence shows bilateral cervical radiculopathies. The need for an in-person examination and/or video or telephonic interview of the Veteran is left to the discretion of the examiner. A complete medical rationale for all opinions expressed must be provided. 5. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Oldroyd, 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.