Citation Nr: 23017489 Decision Date: 03/21/23 Archive Date: 03/21/23 DOCKET NO. 20-10 415 DATE: March 21, 2023 ORDER Service connection for left thumb tendonitis (also referred to as tenosynovitis) is granted. REMANDED Service connection for a left-hand disorder other than tendonitis, to include as due to service in Southwest Asia (SWA), is remanded. Service connection for diabetes, to include as due to service in SWA, is remanded. Service connection for erectile dysfunction, to include as due to service in SWA, is remanded. FINDING OF FACT The Veteran's left thumb tendonitis is at least as likely as not related to service. CONCLUSION OF LAW The criteria for service connection for left thumb tendonitis have been met. 38 U.S.C. §§ 1110, 1112, 1131, 1133, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1989 to March 1992. The case is on appeal from a February 2018 rating decision. In the September 2022 Board decision, the Board granted service connection for a lumbar spine disorder and a psychiatric disorder. It does not appear as though action to implement those grants has been taken. The matter is referred to the RO for any action deemed appropriate. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(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, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection for a left-hand disorder The Veteran claims that his left-hand disorder is related to service. In September 1989, the Veteran underwent left thumb surgery. For left gamekeeper's thumb. The Veteran is already service-connected for left thumb degenerative changes. The question currently before the Board is whether the Veteran has additional left-hand disabilities which are related to service. The Veteran underwent a VA examination of the left thumb, along with number of other claimed disabilities, in November 2009. The Veteran reported pain and dropping items due to the left thumb giving way at times. Another VA examination of the left hand was conducted in January 2016, at which time diagnoses of degenerative arthritis, tendonitis of the left thumb, and mild carpal tunnel syndrome unrelated to the left thumb. The Veteran noted a current burning, tingling pain radiating from his thumb to his forearm. The Board remanded the claim in December 2022 to obtain a medical opinion as to the Veteran's left-hand disorder. The examiner opined that left thumb arthritis and tenosynovitis were related to service. With regard to tenosynovitis, the examiner opined that the force of the dislocation would affect the left thumb tendons. The Board finds that the December 2022 medical opinion is adequate to address direct service connection the claim as the examiner discussed the Veteran's health history in light of the relevant medical principles. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, the examiner reviewed the nature of the in-service injury to distinguish between the Veteran's claimed left-hand disorders and in doing so noted that tenosynovitis was related to service given the force of the injury causing the left thumb dislocation. The Board finds that the Veteran's left thumb tendonitis (tenosynovitis) is at least as likely as not related to service. The December 2022 medical examiner clearly explained that the left thumb tendons would have been affected by the Veteran's in-service left thumb injury. Thus, service connection for left thumb tendonitis is granted. The remaining diagnosis of left wrist carpal tunnel syndrome is addressed below. REASONS FOR REMAND 1. Service connection for a left-hand disorder other than left thumb tendonitis A remand is necessary for an addendum medical opinion as to the etiology of the Veteran's remaining left-hand disorder, carpal tunnel syndrome. For veterans who served in SWA, qualifying chronic disabilities which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis is presumed to be related to service. 38 C.F.R. § 3.317. A qualifying chronic disability means and undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI) that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders. Id. A MUCMI is a diagnosis without conclusive pathophysiology or etiology. Id.; see also Stewart v. Wilkie, 30 Vet. App. 383 (holding that an illness is not a MUCMI where both the etiology and pathophysiology are partially understood). The December 2022 VA examiner opined that carpal tunnel syndrome was less likely than not related to service. While dislocation of the thumb could predispose the Veteran to develop arthritis in the thumb and may affect the tendons of the thumb, the in-service thumb injury would not affect other joints in the hand or carpal tunnel syndrome which involves compression of the median nerve at the wrist. Further, carpal tunnel syndrome was less likely than not due to exposures while serving in SWA as carpal tunnel syndrome was an anatomic or pathophysiologic mechanism by which any kind of exposure could have caused carpal tunnel syndrome. While the December 2022 medical opinion adequately addresses the question of direct service connection, the examiner did not provide any information as to how carpal tunnel syndrome arose in this Veteran. Without both an etiology and pathophysiology that is at least partially known, the disorder would be a MUCMI. Thus, a remand is necessary to clarify whether the Veteran's carpal tunnel syndrome has a known etiology and pathophysiology. Additionally, while the examiner noted that the Veteran's service-connected disabilities did not cause his carpal tunnel syndrome, clarification is needed as to whether the Veteran's service-connected disabilities aggravates his nonservice connected carpal tunnel syndrome. 2. Service connection for diabetes The Board finds that a remand of the claim for service connection for diabetes is warranted to obtain an addendum medical opinion. In September 2022, the Board remanded the claim to afford the Veteran a VA examination of his diabetes. In part, the Board requested that the examiner on remand opine as to whether the Veteran's diabetes was a MUCMI. However, under 38 C.F.R. § 3.317(a)(2)(ii), diabetes is not a MUCMI. Therefore, that portion of the medical opinion obtained on remand was unnecessary and will not be discussed. The Veteran was afforded a VA examination of his diabetes in December 2022. The examiner opined that the Veteran's diabetes was less likely than not related to service as there was scant data to support a nexus between diabetes and burn pit exposure. In fact, there was no epidemiologic evidence that veteran serving in SWA are at higher risk to develop diabetes, even considering the potential exposures during service. Rather, diabetes has well-established risk factors, including family history, diet, and sedentary lifestyle. Therefore, in the absence of chronicity during service, a post-service event, illness, or injury was considered to be a more likely etiology. The Board finds that the December 2022 medical opinion is adequate to address direct service connection as the examiner discussed the Veteran's health history in light of the relevant medical principles. See Nieves-Rodriguez, supra. However, in August 2020, the Veteran's doctor stated that the Veteran's fibromyalgia led to obesity which caused his lumbar spine disorder. See also September 2022 Board decision. Because the December 2022 examiner noted obesity as a risk factor for diabetes, a remand is necessary to obtain a new medical opinion as to the whether the Veteran's diabetes was caused or aggravated by his service-connected fibromyalgia with obesity as an intermediary step. Walsh v. Wilkie, 32 Vet. App. 300, 302 (2020); see also Garner v. Tran, 33 Vet. App. 241 (2021) (outlining the evidence necessary to raise secondary service connection with obesity as an intermediary step as a theory of entitlement). 3. Service connection for erectile dysfunction The Board finds that a remand of the claim of service connection for erectile dysfunction is necessary. The December 2022 examiner stated that the etiology of the Veteran's erectile dysfunction was most likely diabetes. Thus, the claim for service connection for erectile dysfunction is inextricably intertwined with the claim of service connection for diabetes being remanded herein. Because the Board is remanding the claim of service connection for diabetes, the Board must also remand the claim of service connection for erectile dysfunction. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Obtain an addendum medical opinion as to the etiology of the Veteran's left wrist carpal tunnel syndrome. Specifically, the examiner should determine whether: a) The Veteran's left wrist carpal tunnel syndrome has both an etiology and pathophysiology that is at least partially known. b) The Veteran's service-connected left thumb disorders aggravates his left wrist carpal tunnel syndrome. A complete rationale should be provided for any opinion rendered. 2. Obtain an addendum medical opinion as to the etiology of the Veteran's diabetes. Specifically, the examiner should opine as to whether: It is at least as likely as not that the Veteran's diabetes was caused or aggravated by his fibromyalgia, to include as due to obesity as an intermediate step. A complete rationale should be provided for any opinion rendered. Please consider the August 2020 statement from the Veteran's doctor stated that the Veteran's fibromyalgia and depression led to obesity. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. George 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.