Citation Nr: 23040887 Decision Date: 07/26/23 Archive Date: 07/26/23 DOCKET NO. 18-25 676A DATE: July 26, 2023 REMANDED Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to service connection for nerve damage to neck is remanded. Entitlement to service connection for carpal tunnel syndrome left wrist is remanded. Entitlement to service connection for carpal tunnel syndrome right wrist is remanded. REASON FOR REMAND The Veteran served on active duty in the U.S. Army from May 1979 to May 1983. This appeal comes to the Board of Veterans' Appeals (Board) from a April 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified during a virtual Board hearing in March 2023 before the undersigned Judge. A transcript is associated with the file. COPD The Veteran contends that his currently diagnosed COPD is related to service, to include exposure to ammonium picrate. In March 1976, the Veteran was seen for complaints of chest congestion, a cough and chest wall pain. The Veteran denied having allergies. The Veteran reported that he was a smoker and had stopped smoking. See January 2016 STR-Medical, p. 3. In a February 2010 VA treatment record, the Veteran reported that he smoked for 22 years and quit 8 years prior. He had a diagnosis of COPD. See January 2016 Capri, p.90. In an October 2015 statement, the Veteran reported that he first noticed his condition in 1981, during his annual fitness test 2-mile run. He stated he was able to run the first mile, but he found himself out of breath and had to walk the second mile, barely making it within the time limit. The following year, the Veteran stated he was unable to finish the first mile and was given an hour of physical activities. He stated that classes were given for field stripping cigarettes and night smoking. The Veteran quit smoking in 1998 and a few years later began treatment at a VA facility. See November 2015 VA 21-4138 Statement in Support of Claim. In a May 2016 private treatment record, a private clinician indicated that the Veteran was possibly showing symptoms of COPD while on active duty, but it was unclear if his COPD was related to his active duty. See May 2016 Medical Treatment Record-Government Facility, p. 2. In March 2018, the Veteran was afforded a respiratory VA examination. The examiner noted a diagnosis of COPD from 1977. The Veteran reported that he was not treated in 1977, but by 1980 he could not run more than a mile. He also noted that he experienced shortness of breath which had continued. The condition had an impact on the Veteran's ability to work, because of the difficulty with occupational tasks requiring exertion activities such as fast walking, running and climbing stairs. The examiner found that it was less likely than not the Veteran's COPD was incurred in or caused by service. The examiner stated: "The above opinion is based on thorough C-file review, review of all available medical records and current peer reviewed medical literature. Based on today's physical examination, Veteran's history, and VBMS, there is currently insufficient evidence to suggest the Veteran's diagnosis of COPD was incurred in or caused by or during service. There is one record that contains an in-service note that mentions respiratory symptoms such as purulent, cough, and productive of sputum. However, this single record was the only one found related to respiratory conditions and it's not sufficient to establish that the COPD began during service." However, the examiner's rationale is inadequate, as the examiner based his opinion on the lack of evidence in-service. Additionally, as noted below the Veteran indicated he was exposed to toxic chemicals in-service from gunpowder. There was no discussion as to whether the Veteran's COPD could have been caused by hazardous chemicals or toxins. While the examiner mentioned the Veteran's statements of shortness of breath and being unable to run, the examiner did not consider these statements in his opinion or discuss the Veteran's October 2015 lay statement, which indicated that he was a smoker and quit in 1998. In his March 2023 hearing testimony, the Veteran stated he was exposed to gunpowder and chemicals while assigned to the tank squadron. He stated: "The gas was known as ammonium picrate, which is a toxic fume or gas. Every other month a tank company would go to a live fire range. And I would stand behind the range waiting for the tower to call me when a certain tank was not answering their radio. And while everybody else was still firing, I would take a radio out to that tank and replace it. So, the air was nothing but toxic gas, dust, and diesel fumes." The Veteran further testified that he was exposed to ammonium picrate for 30 days, every other month for 2 years. He testified that the medic at times brought him oxygen due to shortness of breath from the gas and fumes. The Veteran further testified that he began smoking in-service but did not smoke prior to service. See March 2023 Hearing Transcript. There is no competent medical opinion of record addressing whether the Veteran's currently diagnosed COPD is related to his active military service, including exposure to ammonium picrate. As such, the Board finds that a remand for another VA medical opinion is necessary. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Neck The Veteran contends his neck condition was incurred in or caused by service. In March 2010, the Veteran was diagnosed with chronic neck spasms. See January 2016 Capri, p. 88. In an October 2015 statement, the Veteran reported that the condition began due to bouncing around in an armored vehicle wearing a steel helmet which weighed more than his head. He stated that his neck did not have time to adjust to the added weight and put excessive stress on his neck, causing a lot of pain. The Veteran stated that he took aspirin in-service and after discharge took Valium twice a day. Once he began going to the VA, he was prescribed medication for his nerves. See November 2015 VA 21-4138 Statement in Support of Claim. In a May 2016 private treatment record, a private clinician found it was at least as likely as not that the Veteran's neck condition was related to active duty. See May 2016 Medical Treatment Record-Government Facility, p. 2. In March 2018, the Veteran was afforded a VA examination. The examiner found that the Veteran never had a diagnosis of a neck condition. The examiner noted that the onset was 1977 and there was no trigger event. The examiner found that it was less likely than not that the Veteran's condition was incurred in or caused by service. The examiner stated: "The above opinion is based on thorough C-file review, review of all available medical records and current peer reviewed medical literature. Based on today's physical examination, Veteran's history, and VBMS, there is currently insufficient evidence to suggest the Veteran's diagnosis of neck nerve damage was incurred in or caused by (the) during service. There was no neck condition found on today's exam, and the reviewed records document some prior back injuries, but nothing was found related to neck pain from wearing a helmet." During the March 2023 hearing, the Veteran stated that he had problems with his neck since service. He testified a few years ago he went to see a chiropractor and began treatment for his neck in the early to mid-90's. The Veteran testified that after service he was not doing work that involved strenuous activity. He testified he was using lidocaine ointment for his neck and back. The Veteran testified that during his neck VA examination, the examiner did not have access to all of his documents when the examination occurred. See March 2023 Hearing Transcript. In this case, a remand is required for an adequate VA examination. The March 2018 VA examination indicated that the Veteran did not have a diagnosis for a neck disability but failed to address whether the Veteran's neck pain causes functional impairment. Pain that caused functional impairment is required for pain to be considered a disability for VA purposes. Saunders v. Wilkie, 886 F. 3d (Fed. Cir. 2018). Left and Right Carpal Tunnel The Veteran seeks service connection for left and right wrist carpal tunnel syndrome, asserting that wrist problems began during service or are related to typing in-service. In an November 2015 statement, the Veteran reported that his condition began in 1976. He stated that being a radio operator required a lot of repetition. He said that after four years of doing the same thing, he began to wear wrist bands and an OD watch band, to take some of the tension off of his wrists. He stated that 20 years ago he purchased proper bands for carpal tunnel and changes them as new designs come out. He indicated his doctor told him to continue to use the braces to ease the pain and slow down further damage. See November 2015 VA 21-4138 Statement in Support of Claim In a May 2016 private treatment record, a private clinician found it was at least as likely as not that the Veteran's bilateral carpal tunnel was related to active duty. See May 2016 Medical Treatment Record-Government Facility, p. 2. This opinion is inadequate as it did not provide a rationale for it. In March 2018, the Veteran was afforded a peripheral nerves VA examination. The examiner indicated that the Veteran was diagnosed with bilateral carpal tunnel syndrome in 2018. The Veteran reported that he was a typewriter and started having numbness and tingling in his fingers. The Veteran did not have any treatment in service and his condition persisted since service. The Veteran indicated that he bought wrist braces for the condition. The examiner found that it was less likely than not the Veteran's condition was caused by typing in-service. The examiner stated: "The above opinion is based on thorough C-file review, review of all available medical records and current peer reviewed medical literature. Based on today's physical examination, Veteran's history, and VBMS, there is currently insufficient evidence to suggest the Veteran's diagnosis of CTS was incurred in or caused by service." During the March 2023 Board hearing, the Veteran testified that he worked in a communications center, where he did not just type but had to slam on keys, for 12 hours at a time. He stated that he had nerve problems in both hands since that time. The Veteran testified that after service he did warranty paperwork and then was an electrician. See March 2023 Hearing Transcript. The Board acknowledges that the March 2018 VA examiner diagnosed the Veteran with carpal tunnel syndrome, but there is no adequate medical opinion regarding whether such disability is related to service. The March 2018 examiner opined that the Veteran's carpal tunnel syndrome was less likely than not due to typing in-service but provided no rationale. He merely stated there was not sufficient evidence to indicate whether the Veteran's condition was due to his service. The examiner did not provide a rationale as to why the Veteran's disability was not related to service and there was no mention of the Veteran's lay statements of record. Accordingly, remand is warranted to obtain a new VA medical opinion. These matters are REMANDED for the following action: 1. Schedule the Veteran for a neck VA examination with an appropriate clinician. a. The examiner should identify any neck disabilities the Veteran has experienced at any time during the appeal period, even if resolved. The examiner is advised that for VA purposes a "disability" includes pain causing functional impairment of earning capacity. b. For any disability identified (to include "pain" causing functional impairment of earning capacity), the examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability had an onset in service or is otherwise related to service, to include an injury from a helmet. 2. Obtain an addendum medical opinion from an appropriate clinician regarding the nature and etiology of the Veteran's currently diagnosed COPD. The examiner must be provided access to the electronic claims file and indicate review of the claims file in the examination report. a. The examiner must provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the currently diagnosed COPD is etiologically related, in whole or in part, to the Veteran's active military service, to include exposure to environmental hazards, including toxic chemicals such as ammonium picrate, from gunpowder. A complete rationale must be given for all opinions and conclusions expressed. If the examiner determines that the Veteran's condition has another cause, to include his smoking history, the examiner must explain their reasoning. b. The examiner must specifically address the March 1976, treatment record, the various lay statements of record including the October 2015 statement from the Veteran, the May 2016 statement from a U.S. Army medic and also review and discuss the article submitted by the Veteran in March 2023. 3. Next, obtain an addendum medical opinion from an appropriate clinician regarding the nature and etiology of the Veteran's currently diagnosed bilateral carpal tunnel syndrome. a. The examiner should opine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability had an onset in service or is otherwise related to service, to include typing in-service. b. The examiner should specifically address the Veteran's reports of continuous pain since service, his service treatment records and the May 2016 private opinion that indicated that the Veteran's carpal tunnel is at least as likely than not connected to his service. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). 4. A complete rationale must be provided for all opinions expressed. PAULA B. McCARRON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Long-Ellis, Erica 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.