Citation Nr: 23020135 Decision Date: 03/31/23 Archive Date: 03/31/23 DOCKET NO. 17-00 409 DATE: March 31, 2023 ORDER Entitlement to service connection for right second, third, and fourth trigger fingers (hereinafter, right hand disability) secondary to service-connected right upper extremity radiculopathy is granted. REMANDED Entitlement to service connection for a right shoulder disorder, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected disabilities, is remanded. FINDING OF FACT Resolving all doubt in favor of the Veteran, his right hand disability is proximately due to his service-connected right upper extremity radiculopathy, to include carpal tunnel syndrome, right median nerve. CONCLUSION OF LAW The criteria for service connection for a right hand disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1973 to July 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from August 2015, June 2016, and February 2017 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, these matters were previously before the Board in August 2019 and December 2021, when they were remanded for further development. The case now returns for further appellate review. 1. Entitlement to service connection for a right hand disability, to include as secondary to service-connected disability, is granted. The Veteran contends that his right hand disability was caused by his service-connected right upper extremity radiculopathy, to include carpal tunnel syndrome of the right median nerve. See June 2017 VA Form 21-4138 Statement in Support of Claim. Specifically, he reported that scar tissue from his in-service right arm injury was compressing his ulnar nerve, causing pain, swelling, and loss of use of his right hand. See June 2017 NOD; August 2017 VA Form 9. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may not be established on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). As an initial matter, VA treatment records the Veteran has a current diagnosis of trigger fingers in the right second, third, and fourth digits, which cause pain and discomfort. See, e.g., June 2020 CAPRI. Additionally, the Veteran, in pertinent part, is in receipt of service connection for right upper extremity radiculopathy to include carpal tunnel syndrome of the right median nerve, effective March 17, 2017, and right arm scarring status-post right bicep repair, effective November 17, 2016. A review of the post-service treatment records shows that the Veteran was initially afforded a VA examination to evaluate the nature and etiology of his claimed right hand pain in May 2017. The examiner indicated that the Veteran did not have a current diagnosis associated with his claimed right hand pain but noted that he had been diagnosed with right trigger fingers. During the examination, the Veteran reported that his right hand pain manifested three years prior to the date of the examination. Following the examination, the examiner found that the Veteran's hand issues appeared to be from peripheral nerve issues and muscle/blood vessel trauma, rather than from a specific hand problem. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's right hand disability was proximately due to or the result of his service-connected residuals of a right arm laceration. In support of his opinion, the examiner explained that the Veteran's only diagnosed right hand disability, trigger finger, was not related to his forearm laceration. See May 2017 C&P examination. The Veteran also underwent a VA examination in December 2019. The examiner noted that the Veteran had been diagnosed with right trigger finger. After performing the examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed trigger finger was incurred in or caused by his in-service laceration. In support of her opinion, the examiner noted that the medical literature showed that trigger finger was one of the most common causes of hand pain in adults and that the prevalence thereof was higher among patients with diabetes mellitus, rheumatoid arthritis, and conditions that caused systemic deposition of protein such as amyloidosis. She further stated that the majority of trigger fingers were idiopathic and that symptoms of such usually began spontaneously, without a prior history of trauma or change in activity level. However, the examiner noted that some observational reports suggested an association with occupational or repetitive activities, but found that such findings were controversial. The examiner also found relevant that the Veteran had a history of diabetes mellitus and, hence, it was less likely than not that the Veteran's right hand disability was incurred in or caused by his service-connected laceration. See December 2019 C&P examination. The Board notes that the December 2019 VA examiner provided a substantively identical opinion regarding the etiology of the Veteran's reported right hand pain in June 2020. See June 2020 C&P examination. VA last obtained an addendum medical opinion in September 2022. After performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed right hand disability was incurred in or caused by the claimed in-service injury, event, or illness. In support of her opinion, the examiner found that there was "scant data supporting a nexus" between the Veteran's current disability, which was not present until 2017, and his active duty service. In this regard, the examiner found that without chronicity during or after the Veteran's active service, a post-service event, illness, or injury was considered to be a more likely etiology of his diagnosed right hand disability. However, the examiner also opined that it was at least as likely as not that the Veteran's right hand disability was proximately due to or the result of his service-connected carpal tunnel syndrome. In support of her opinion, the examiner explained that the current severity of the Veteran's carpal tunnel syndrome of the right upper extremity warranted association with the Veteran's right hand disability based on proximity. In addition, she noted that the Veteran's diagnosed right hand disability began subsequent to his service-connected carpal tunnel syndrome and was the direct result thereof. The examiner further explained that a nexus between such disabilities was supported by the Veteran's treating physician's findings. Upon review, the Board finds the September 2022 VA addendum medical opinion to be the most probative evidence of record. In this regard, the Board finds that the May 2017 VA medical opinion was not supported by a rationale, and is therefore inadequate to adjudicate the issue on appeal. Similarly, the Board finds the December 2019 and June 2020 VA medical opinions to be inadequate as the examiner's conclusions do not follow the data cited therein. Specifically, although the examiner who proffered both opinions appears to state (though, notably, does not actually say) that the Veteran's trigger finger was more likely caused by diabetes than by his service-connected laceration, the medical literature cited in the opinion does not indicate that trigger fingers are caused by diabetes. Rather, the referenced materials state that the prevalence of trigger finger is higher among patients with diabetes, and that the majority of trigger fingers are idiopathic or cannot be identified. Moreover, the Board finds the fact that most cases of trigger finger do not have a prior history of trauma does not imply that trauma is not a potential cause of trigger finger. Thus, the Board finds that the December 2019 and June 2020 medical opinions are internally inconsistent and lack sufficient rationale to support the conclusions reached; thus, both medical opinions are also inadequate to adjudicate the issue on appeal. In contrast, the Board finds the September 2022 VA medical opinion regarding aggravation to be consistent with the record, to include the Veteran's diagnosed trigger finger of the right second, third, and fourth digits, his assertions of right hand pain, and his history of right upper extremity neuropathy with carpal tunnel syndrome. Further, the opinion is unequivocally stated and supported by a cogent rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that to have probative value, the opinion provider must be fully informed of the pertinent factual premises, provide a fully articulated opinion, and provide a supportive reasoned analysis). Accordingly, the Board affords great probative weight to such opinion, which supports entitlement to service connection on a secondary basis. Therefore, resolving all doubt in favor of the Veteran, service connection for a right hand disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 2. Entitlement to service connection for a right shoulder disorder, to include as secondary to service-connected disabilities, is remanded. 3. Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected disabilities, is remanded. In December 2021, the Board remanded the Veteran's service connection claims to obtain an addendum medical opinion to determine the nature and etiology of his right and left shoulder disabilities. To this end, the Board, in pertinent part, asked the examiner to opine as to whether it was at least as likely as not that the Veteran's shoulder disability had its onset during service, within a year of his separation from service, or was otherwise related to an in-service injury or event and, in doing so, to address the Veteran's lay testimony asserting that he has experienced continuous shoulder pain since his in-service injury. In addition, the Board indicated that the examiner should opine as to whether it was at least as likely as not that the Veteran's bilateral shoulder disability was aggravated by any of his service-connected disabilities. Upon review, the Board notes an addendum medical opinion was obtained in September 2022. After performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran's claimed degenerative joint disease of the bilateral shoulders was directly related to his active duty service as there was "scant data supporting" a nexus between the current bilateral shoulder disability, diagnosed as degenerative joint disease, and his active duty service. In this regard, the examiner noted that the Veteran reported burning pain through his shoulders in 1975 during the "refrigerator incident" and that he experienced right arm pain due to a scar, rather than an orthopedic shoulder injury, in 1977. However, the examiner found no evidence of chronicity of care, concerns, or pathology for an orthopedic shoulder condition and indicated that there was no radiologic evidence of disruption to the articular surface of the joint at the time of injury. As such, the examiner concluded that the Veteran's shoulder-related complaints during service were acute, rather than orthopedic, in nature, and determined that it was most likely that the Veteran's diagnosed shoulder disabilities represented a natural aging process. As such, the examiner found that, without chronicity during or after service, a post-service event, illness, or injury or aging was considered to be a more likely etiology. The examiner further opined that it was less likely than not that the Veteran's degenerative joint disease of the shoulders or any other diagnosed shoulder disability was aggravated beyond its natural progression by his service-connected disabilities, to include right bicep rupture, radiculopathy of the left upper extremity, radiculopathy of the right upper extremity including carpal tunnel syndrome of the right medial nerve, degenerative joint disease of the neck, and scarring. In support of such opinion, the examiner found that no aggravation was plausible because the Veteran's shoulder disability was not medically or physiologically related to his service-connected disabilities. See September 2022 C&P examination. After consideration of the aforementioned, the Board finds the September 2022 VA examiner's opinion to be insufficient for the purpose of determining entitlement to service connection. Specifically, the September 2022 VA examiner did not consider the Veteran's lay testimony asserting that he has experienced continuous shoulder pain since his in-service injury, as directed by the December 2021 Board Remand. Thus, a remand is warranted for an addendum opinion. 4. Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected disabilities, is remanded. As noted above, the Board remanded the Veteran's service connection claim in December 2021 to obtain a medical opinion regarding the nature and etiology of the Veteran's right elbow disability. Specifically, the Board, in pertinent part, asked the examiner to identify any right elbow disabilities diagnosed from November 2016 to the present, to include whether the Veteran has had pain in his right elbow that resulted in functional loss since November 2016, and in doing so, to address the lay testimony regarding right elbow pain. The Board also asked the examiner to opine as to whether it was at least as likely as not that any diagnosed right elbow disabilities or pain were related to an in-service injury or event and whether they were caused or aggravated by any of his service-connected disabilities. Upon review, the Board notes that VA medical opinions were obtained in September 2022. To this end, after performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran's claimed right elbow disability was proximately due to, the result of, or aggravated beyond its natural progression by his service-connected disability. In support of the opinion, the examiner explained that there was no treatment notes or evidence showing that the Veteran had a chronic right orthopedic elbow condition. The examiner further explained that there was no chronicity of care from the Veteran's active duty service or any concerns or pathology for an orthopedic right elbow disability. The examiner acknowledged that the Veteran was diagnosed with epicondylitis in 2005 and again during his May 2017 VA examination; however, the examiner found no evidence to indicate that the diagnosis was chronic or that it had manifested while he was serving on active duty or proximately thereafter. The VA examiner also found that the Veteran's service-connected bicep disability was most likely traumatic and was caused by an injury he sustained opening a window in 2006. In this regard, the examiner explained that contrary to the prior medical opinion purporting a nexus, the Veteran's service treatment records failed to show any injury, surgery, or surgery residuals related to the bicep tendon insertion above the elbow. Thus, the examiner found that, given the absence of evidence showing pathology for a chronic orthopedic right elbow disability, no nexus existed between the Veteran's claimed right elbow disability and his active duty service. The examiner provided identical rationales to support her opinions that it was less likely than not that the Veteran's claimed right elbow disability was proximately due to, the result of, or aggravated beyond its natural progression by his service-connected disabilities. See September 2022 C&P examination. After consideration of the aforementioned, the Board finds the September 2022 VA examiner's opinion insufficient for the purpose of determining entitlement to service connection. First, the September 2022 VA examiner did not indicate whether the Veteran's right elbow pain caused functional impairment or consider the Veteran's lay testimony asserting that he has experienced continuous right elbow pain since his in-service injury, as directed by the December 2021 Board Remand. In addition, the examiner failed to provide a rationale to support her opinion that it was less likely than not that the Veteran's claimed right elbow disability was proximately due to, the result of, or aggravated beyond its natural progression by his service-connected disabilities. To the contrary, the examiner disagreed with a prior examiner's conclusions regarding the Veteran's service-connected right bicep disability without providing any rationale specific to his claimed right elbow disability. Consequently, the Board finds a remand is necessary to obtain an addendum opinion addressing the matter. The matters are REMANDED for the following actions: 1. Obtain an addendum medical opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's diagnosed right and left shoulder disabilities. The need for an additional examination is left to the discretion of the examiner selected to provide the opinion. After a review of the record, the clinician should address the following inquiries: Provide an opinion as to whether it is at least as likely as not that any shoulder disability had its onset during service or are otherwise etiologically related to his military service. The examiner must address the Veteran's lay statements regarding his history of symptomatology. A rationale should be provided for any opinion rendered. 2. Obtain an addendum medical opinion from an appropriately qualified examiner to determine the nature and etiology of any current right elbow disability. The need for an additional examination is left to the discretion of the examiner selected to provide the opinion. After a review of the record, the clinician should address the following inquiries: (a.) Identify all right elbow disabilities that have been diagnosed during the pendency of the appeal, even if such has since resolved or become asymptomatic. By "current disability" the Board means: (1) any disability diagnosed by the examiner; (2) any relevant diagnosis during the appeal period (beginning in November 2016); and/or (3) symptoms resulting in functional impairment but not otherwise warranting a specific diagnosis. The examiner must consider all diagnoses of record related to the Veteran's claimed right elbow disability, to include medial epicondylitis of the right elbow. If the examiner determines that any prior diagnoses are incorrect, he or she should provide an explanation for why the diagnosis was in error. (b.) For each diagnosed right elbow disability, provide an opinion as to whether it is at least as likely as not that such had its onset in, or is otherwise related to, the Veteran's military service. (c.) For each diagnosed right elbow disability, provide an opinion as to whether it is at least as likely as not that the Veteran's shoulder disabilities were (i) caused or (ii) aggravated by a service-connected disability. A rationale should be provided for any opinion rendered. M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.