Citation Nr: 22043876 Decision Date: 08/02/22 Archive Date: 08/02/22 DOCKET NO. 17-24 042 DATE: August 2, 2022 ORDER Entitlement to service connection for a right wrist disability is denied. FINDING OF FACT The Veteran's right wrist disability is not causally or etiologically related to his 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, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 2011 to December 2013 in Afghanistan, and most recently from December 2020 to December 2021 in support of Operation Enduring Freedom. He also had an earlier period of active duty for training (ACDUTRA) from September 2009 to February 2011 and other periods of inactive duty for training (INACDUTRA). This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified before the undersigned Veterans Law Judge via videoconference hearing. A copy of the hearing transcript is of record and has been reviewed. In February 2020, the Board granted service connection for tinnitus and left foot disability and remanded the claims for service connection for a right wrist disability, left knee disability, bilateral hearing loss, and a right foot disability, which was expanded to bilateral foot disability, for additional development. In an October 2020 rating decision, the RO granted service connection for left knee tendonitis, bilateral hearing loss, and bilateral plantar fasciitis; these awards represent a full grant of the benefits sought, and the claims are no longer in appellate status. In September 2021, the Board again remanded the claim for a right wrist disability to obtain an addendum medical opinion. In December 2021, the Board remanded the claim to obtain service treatment records pertaining to the Veteran's most recent period of service. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the appellant and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. As to lay evidence, a layperson is competent to describe symptoms and readily observable disorders but does not have the education, training, or expertise to formulate a competent medical opinion linking matters which are of a complex medical nature and beyond the ken laypersons and which cannot be diagnosed based on observation or analysis of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372 (2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316. A claimant bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Entitlement to service connection for a right wrist disability, diagnosed as tendonitis The Veteran in this case asserts that his right wrist disability is specifically related to his active duty service in Afghanistan; specifically, being right-hand dominant, picking up rucksacks and gear, getting off the ground with his right hand, and general overuse during service, and that his pain in the right wrist has persisted since service. See Hearing Transcript, dated January 2020. The Veteran does not contend that the right wrist disability is related to a period of ACDUTRA or INACDUTRA. The Veteran has a current diagnosis of tendinitis of the right wrist. See VA C&P Exam, dated October 2020. At a Periodic Health Assessment (PHA) conducted in May 2011, the Veteran denied all symptoms, including joint pain. At Pre-Deployment Health Assessments in September 2011 and December 2011, it was noted that the Veteran was in excellent health and there were no reports of any symptoms, including swollen, stiff or painful joints, or numbness or tingling in the hands. The Veteran was deployed in Afghanistan from January 15, 2012, to November 24, 2012. At a November 2012 Post-Deployment Health Assessment, the Veteran indicated that he was in "about" the same health as before he was deployed. He was not wounded, injured or assaulted, and denied any swollen, stiff, or painful joints. The Veteran requested a line of duty determination only for right shoulder and upper back pain for which he was treated during service. At a May 2013 Post-Deployment Health Re-Assessment, the Veteran reported that numbness in the hands and feet bothered him "a lot," and that he had been having pain in the arms, legs or joints for the past month. A referral was issued for right shoulder, arm, hand numbness. In March 2014, the results of a PHA note pain in the elbows with occasional numbness down the arms. At a March 2015 VA primary care visit, the Veteran reported no active medical problems; bilateral wrist examination as normal and Tinel's testing was negative. The Veteran requested x-rays of his right shoulder. On a March 2015 PHA, the Veteran reported a history of pain in the knees, right shoulder, back and right wrist. He denied chronic pain. The examiner commented that he had topical analgesics and x-rays pending. At a May 2016 PHA, the Veteran reported knee joint pain and chronic pain in the right shoulder and knees. At an October 2017 PHA, the Veteran reported right shoulder joint pain and chronic knee pain. At the January 2020 hearing, the Veteran testified that he could not recall a specific isolated event of right wrist injury but believes that is due to overuse since he is right-hand dominant; that he did not have time to go to sick call; did not mention it when deactivated as he was pushed through the process; and that he mentioned his wrist when he had physical therapy for his shoulder was told some things to do at home for it. He also testified that he has no diagnosis for his right wrist other than pain. The Veteran underwent a VA examination of the right wrist in October 2020, at which time the examiner rendered a diagnosis of tendinitis of the right wrist. The Veteran reported a history of wrist pain from 2012, that he sought care, was treated and has not had care since then. The VA examiner opined that the Veteran's right wrist tendonitis is less likely than not incurred in or caused by service. The examiner reasoned that there was no objective evidence of right wrist injury or symptoms during active duty nor objective evidence of chronicity of care between the end of active duty and onset of the right wrist pain, and the history of the onset of symptoms during active duty was subjective only. The examiner found the lack of objective data to support the reported onset during active duty was inconsistent with medically expected presentation. This opinion is inadequate as it did not discuss the Veteran's lay report of in-service right wrist symptoms. In an October 2021 VA medical addendum, upon review of the medical evidence of record and consideration of the Veteran's lay statements, the examiner opined that the Veteran's right wrist disability was less likely than not incurred in or related to service. The examiner reasoned that the Veteran reported that his pain started in 2013, had continued pain by history on a March 2015 examination with normal clinical examination, and that no further complaints or diagnosis was found. Therefore, the examiner concluded that there was no nexus. A service treatment record dated in October 2021 for the left elbow reflects that the Veteran's range of motion for the right wrist was within normal limits and had muscle strength 5/5. When examined following a motor vehicle accident in November 2021, the right wrist had normal motion and stability with no swelling, nodules, or tenderness to palpation. Phalen's did not show any numbness or tingling in the median nerve distribution, Tinel's sign of the median nerve was negative, and no neurologic weakness of the right wrist was observed. At a November 2021 Report of Medical History for Separation from the Reserves, the Veteran marked that he had painful shoulder, elbow or wrist and numbness or tingling. With respect to the markings, the examiner clarified that the Veteran was service connected for his right shoulder, and right and left knees, had numbness and tingling down both arms into the fingers and had a recent left elbow injury causing sensation down the left arm into the hand and fingers. The examiner further noted that the Veteran had a history of left epicondylitis. After a careful review of the evidence, lay and medical, the Board finds that the Veteran's right wrist disability was not incurred in or related to his active service. There is no competent evidence of a nexus between the Veteran's diagnosed right wrist disability and service. The Board finds the October 2021 VA addendum opinion to be competent, credible, and highly probative. The opinion is supported by adequate rationale based on a review of the claims file; it is factually accurate and contain sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Notably, the examiner concluded that the Veteran's right wrist disability is less likely as not related to service, which included consideration of the Veteran's right wrist pain after and since returning from Afghanistan, his lay statements of overuse, and his March 2015 report of right wrist pain and receipt of exercises for right wrist pain. There are no other medical opinions or other competent medical evidence of record that weigh against the October 2021 VA opinion. Accordingly, the Board finds the October 2021 VA opinion highly probative, competent and persuasive medical evidence in this case. The only evidence of record supporting the contention that the Veteran's right wrist disability is etiologically related to active service is lay evidence submitted by the Veteran. His lay statements however are not competent because the question of etiology of a right wrist disorder is a complex medical question and, as a layperson, the Veteran is not competent to provide an opinion relating it to service. See Kahana at 437 (2011). An opinion of etiology would require knowledge of the complexities of the musculoskeletal system and would involve objective clinical testing and expertise that the Veteran is not competent to perform. On the contrary, the VA examiner possesses expertise and training in the medical field and has provided a competent and probative medical opinion in this case. The October 2021 VA etiology opinion outweighs the lay evidence as to etiology in this case. The Board concludes that the Veteran has not presented competent evidence showing that right wrist disability is related to active service. See Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (holding that it is the claimant's general evidentiary burden to establish all elements of the claim). In consideration of the foregoing, the Board finds that the competent and credible evidence is persuasively against the claim of service connection for the Veteran's right wrist disability and the benefit-of-the-doubt doctrine is therefore not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As such, the claim of entitlement to service connection for a right wrist disability is denied. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Beach, Julia M. 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.