Citation Nr: 23010271 Decision Date: 02/17/23 Archive Date: 02/17/23 DOCKET NO. 18-48 115 DATE: February 17, 2023 REMANDED Entitlement to service connection for a right wrist disorder, including sprains, is remanded. Entitlement to service connection for a left wrist disorder, including sprains, is remanded. Entitlement to service connection for a right hand disorder, including sprains, is remanded. Entitlement to service connection for a left hand disorder, including sprains, is remanded. REASONS FOR REMAND The Veteran had active duty service from December 1990 to April 2003 and from April 2003 to November 2014. In August 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ). A hearing transcript is of record. In April 2022, the Board of Veterans' Appeals (Board) issued a decision which granted service connection for tinnitus while remanding the claims for entitlement to service connection for polyarthritis of the bilateral wrists, bilateral hand and fingers, bilateral ankles and bilateral feet and toes for additional development. After the additional development was completed, the Regional Office (RO) issued a September 2022 rating decision which granted service connection for polyarthritis and ankylosing spondylitis of the right hip, as well as polyarthritis of the left hip, right ankle, left ankle, as well as the right and left foot. Each disability was assigned a 10 percent evaluation, effective December 1, 2014. This decision is considered a full grant of the benefits sought on appeal for those disabilities; accordingly, they are no longer on appeal and will not be addressed herein. Entitlement to service connection for bilateral wrist disorder, including sprains, and bilateral hand and fingers disorders, including sprains, are remanded. The Veteran seeks service connection for polyarthritis of the bilateral hands and fingers as well as his bilateral wrists, reporting that he has experienced varying levels of pain in those joints following his service. As was discussed in the April 2022 remand, at the August 2021 Board hearing, the Veteran testified he suffered a fall during his service around 2006. He fell going down the stairs and landed on his buttocks. For the next two to three months, he started feeling pain all over his body, including his back, feet, hands, ankles, and wrist, including a sausage toe. He saw his patient care management (PCM) physician several times from August until November following his fall, then he saw a rheumatologist in December 2006 or January 2007. He performed some testing to diagnose the Veteran's pain but did not find a definite diagnosis. The Veteran testified the rheumatologist believed the Veteran was suffering from polyarthritis and was given medication. Since leaving the military, the Veteran testified he had been dealing with a low-level pain daily which was constant. Additionally, at the hearing, the Veteran raised the question of whether he suffered from fibromyalgia considering his service in the Gulf War. The Veteran also indicated these conditions may also be secondary to his service-connected lower back and bilateral knees. Specifically, he testified a doctor had indicated that the trauma of his fall and compression in his back could have been the cause of the arthritis condition in the joints in his body. Based upon this testimony, the Board remanded these claims to obtain a VA examination that would address the nature and etiology of the Veteran's wrist and hand pain, including whether it was experienced continuously from his in-service fall, related to his service in the Gulf War, or caused or aggravated by his service-connected degenerative disc and joint disease of the lumbar spine and bilateral knees. In June 2022, VA examinations for the Veteran's wrists as well as hands and fingers were performed. The examiner diagnosed the Veteran with bilateral wrist sprain, as well as bilateral hand sprain. It was noted that a June 2022 radiology report showed no acute findings associated with either his hands or wrists. After examining and reviewing the claims file, the examiner offered unfavorable direct medical opinions. For rationale, the examiner stated there was no objective imagining in the records showing arthritis in either the hands or wrists and that the records were silent for any complaints related to the Veteran's bilateral hand and wrist strains. In support, the examiner highlighted the fact the June 2022 x-ray of the hands and wrists were normal and concluded the conditions were not caused by his service, including his fall. An addendum opinion to the June 2022 VA medical opinion was sought in July 2022 regarding whether the conditions were related to service in the Gulf War. The July 2022 examiner reported the Veteran's diagnoses were related to physical wear and tear and did not meet the criteria for an undiagnosed illness. In August 2022, another VA medical opinion was sought. It was explained to the examiner that the prior two opinions were insufficient because they were based on the lack of medical records during service and the current x-rays now showing arthritis; however, the examiner did not address the Veteran's report of continuity of symptoms from service to present. Further, it was pointed out that the examiner had stated the reason for the Veteran's proposition that the symptoms began in service and thereafter represented the onset of his current disability was rejected was because chronic pain was reported and nothing else, which indicated continuity of symptoms since service. Therefore, an adequate direct and secondary medical opinion was sought. The August 2022 VA examiner responded to the addendum request by stating that although the records and lay statement mentioned joint pain related to the claims of bilateral wrist and hand pain, they did not show continuity of treatment and the symptoms began before the service-connected conditions. Furthermore, it was noted that the Veteran was diagnosed with poly-arthralgia, not to be confused with poly-arthritis, due to elevated erythrocyte sedimentation rate (ESR) in December 2006. The examiner pointed out that previous x-rays related to the claims did not show arthritis, nor did the current June 2022 x-ray. Therefore, the examiner concluded it was less likely than not that the currently diagnosed conditions related to the claims were incurred in or caused by the Veteran's service injury. Regarding the Veteran's secondary service connection theory of entitlement, the examiner noted the Veteran was service-connected for degenerative disc disease and joint disease of the lumbar spine and bilateral knees; however, the upper extremity conditions were unrelated to the service-connected disabilities. Therefore, the examiner concluded they were not proximately caused or aggravated by the service-connected degenerative disc disease and joint disease of the lumbar spine and bilateral knees. Although multiple attempts have been made to obtain an adequate VA medical opinion in this case, the opinions obtained remain incomplete. In particular, although the Veteran does not have a diagnosis of polyarthritis, he does have a diagnosis of bilateral wrist and hand sprains and none of the existing medical opinions address whether these current sprains are caused by his in-service injury. Notably, the Veteran has reported continued pain in those joints following his fall and this contention must be addressed. Furthermore, the examiner's medical opinion addressing the Veteran's secondary service connection theory of entitlement is inadequate because it is conclusory in nature with no rationale provided. Accordingly, for the foregoing reasons, another remand is required in order to obtain adequate medical opinions prior to readjudicating this claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Lastly, the Board notes that based on the diagnosis rendered by the June 2022 examiner, the Board has expanded the conditions of the claims to include all wrist and hand disorders, including sprains, and not just polyarthritis, as originally claimed. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). The matters are REMANDED for the following action: Schedule the Veteran for a VA examination for his bilateral wrist sprain and bilateral hand sprain. The examiner must review the claims file. The examiner is asked to provide a response to the following: Are the Veteran's bilateral wrist sprain and bilateral hand sprain at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service, including a clear discussion of the Veteran's lay reports of continuity of symptomatology following his in-service fall, as well as the impact, if any, of the 2006 diagnosis of poly-arthralgia. In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? Additionally, are the Veteran's bilateral hand sprain and bilateral wrist sprain at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) proximately due to service-connected degenerative disc and joint disease of the lumbar spine and bilateral knees? Are the Veteran's bilateral hand sprain and bilateral wrist sprain at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) aggravated, i.e., worsened beyond its natural progression, by service-connected degenerative disc and joint disease of the lumbar spine and bilateral knees? Provide a rationale to support the opinions. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Churchwell, 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.