Citation Nr: 1749133	
Decision Date: 10/31/17    Archive Date: 11/06/17

DOCKET NO.  08-24 132	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUES

1.  Entitlement to service connection for a left wrist disability, claimed as carpal tunnel syndrome.

2.  Entitlement to service connection for a low back disability.

3.  Entitlement to service connection for a bilateral hip disability.


REPRESENTATION

Appellant represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

B. Whitelaw, Associate Counsel


INTRODUCTION

The Veteran served honorably on active duty in the U.S. Navy from December 1985 to March 2006.

These matters comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions from April 2007 and May 2007 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida.  

The Veteran appeared and testified at a hearing before the Board in St. Petersburg, Florida in July 2009.  A transcript of the hearing has been associated with the Veteran's claims file.

These matters were previously before the Board in July 2009, at which time the Board denied the Veteran's claim for service connection for a low back and bilateral hip disability and remanded the issue of entitlement to a left wrist disability for further evidentiary development.  The Veteran appealed the Board's July 2009 denials to the U. S. Court of Appeals for Veterans Claims (Court), which vacated and remanded the Board's July 2009 denials in a December 2012 Memorandum Decision.  

As the Veterans Law Judge who presided over the Veteran's Board hearing is no longer a member of the Board and the Veteran requested an additional Board hearing, the Board remanded the issues currently on appeal in July 2013 and April 2017 in order to afford the Veteran a hearing before another member of the Board.  Unfortunately, correspondence to the Veteran's last known address informing her of the scheduled Board hearing was returned to VA.  Nonetheless, as this decision represents a full grant of benefits sought on appeal, the Board finds that the Veteran has not been prejudiced by the inability to appear and testify before the Board a second time.


FINDINGS OF FACT

1.  Resolving all reasonable doubt in favor of the Veteran, the evidence demonstrates that her current left wrist disability is etiologically related to her active duty service.

2.  Resolving all reasonable doubt in favor of the Veteran, the evidence demonstrates that her current lumbar strain is etiologically related to her active duty service.

3.  Resolving all reasonable doubt in favor of the Veteran, the evidence demonstrates that her current bilateral hip strain is etiologically related to her active duty service.


CONCLUSIONS OF LAW

1.  The criteria for service connection for degenerative disease of the left wrist have been met.  38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016).

2.  The criteria for service connection for a lumbar strain have been met.  38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016).

3.  The criteria for service connection for a bilateral hip strain have been met.  38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016).

Given the Board's favorable decision in granting service connection for a left wrist disability, a lumbar strain, and a bilateral hip strain, the Board finds that all notification and development actions needed to fairly adjudicate the appeal have been accomplished.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a).  Generally, service connection requires: (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.  See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995).  Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

The Veteran is seeking service connection for each of the disabilities currently before the Board with largely identical theories of entitlement for each.  She contends that she began experiencing pain in her back, hips, and left wrist in service and has continued to experience pain in these joints since she separated from active duty.  

At the July 2009 Board hearing, the Veteran clarified that her back and hip pain initially began in the course of completing strenuous physical activity as an airman early in her naval career and that her pain and symptoms in her back and hips got worse in the final three years of her active duty service after the birth of her children.  The Veteran testified that she also began experiencing left wrist symptoms while serving as an airman and that she subsequently had to frequently type using heavy mechanical typewriters for a large portion of her naval career.  She also indicated that she sought treatment for each of these conditions while in service and has continued to experience symptoms and receive treatment for these disabilities since her separation from active duty in March 2006.

Left Wrist

The Veteran's service treatment records verify that she sought care on active duty in August 1994 for symptoms of wrist and forearm pain and occasional numbness in her fingers.  At that time, she was given a differential diagnosis of early bilateral carpal tunnel syndrome.  Subsequent service treatment records do not contain any significant evidence of any in-service care for symptoms in the Veteran's left wrist.  However, the Veteran was afforded a VA examination just over a year after her separation from service in April 2007.  At that time, the Veteran reported paresthesias and numbness that shot down the median nerve distribution bilaterally and she presented with positive Phalen's and Tinel's signs bilaterally.  She was ultimately diagnosed with bilateral carpal tunnel syndrome in a May 2007 VA addendum opinion. 

A review of the Veteran's post-service clinical records indicates that she sought treatment for her left wrist symptoms in October 2007, at which time she reported chronic bilateral pain in the wrist that appeared to resolve when she ceased typing or repositioned her wrists.  In a January 2008 follow-up visit, the Veteran reported that she had had chronic bilateral pain in her wrists for 17 years.  She ultimately underwent an x-ray study of her hands in February 2008 that confirmed the presence of mild degenerative changes in each hand with the left greater than the right.  The Veteran again repeated to her treating clinicians the longstanding nature of her chronic left wrist symptoms at a clinical visit in June 2008, in her July 2008 VA Form 9, and at the July 2009 Board hearing.

The Board notes that the Veteran is competent to report the observable symptoms of pain, numbness, and tingling and to provide a history of when these symptoms began and whether the symptoms were intermittent, continuous, or progressive in nature or severity.  The Board also finds no reason to doubt the sincerity of her lay statements and notes that the consistency of the timeline provided by the Veteran to treating clinicians, the Board, and the VA medical examiners underscores the credibility and persuasiveness of the Veteran's statements.  

In response to the Board's July 2011 remand directives, the Veteran was afforded an additional VA medical examination in September 2011.  At that time, the Veteran again reported sharp pains in her fingers that she felt started in 1991 on active duty service.  The Veteran also noted that she did engage in therapy for this condition for eight months after her retirement from the U.S. Navy.  The clinician who performed this examination provided a fairly detailed recitation of the medical history in the record, as it relates to any treatment for a left wrist condition.  The VA examiner disagreed with the diagnosis of carpal tunnel syndrome, noting that the Veteran's electrodiagnostic test results were negative, and instead stated that the Veteran had only mild degenerative changes in the left wrist, as documented by the February 2008 x-ray images.  Ultimately, the examiner opined that these degenerative changes were less likely than not incurred or aggravated as a result of active military service.  

In support of this opinion, the September 2011 VA examiner indicated that the Veteran was treated for a left wrist ganglion cyst in September 1991 and subsequently received care in August 1994 for wrist pain.  He stated further that the Veteran's differential diagnosis of carpal tunnel syndrome was ruled out by subsequent EMG testing and that the Veteran continued to perform the same type of typing activities after the August 1994 episode of wrist pain for 12 more years.  

The Board notes that, unlike the Veteran, this VA clinician is competent to provide a medical opinion regarding the medically complex issue of the etiology of the Veteran's current left wrist disability.  However, the Board finds that this opinion fails to account for the Veteran's repeated, competent, and credible assertions regarding the ongoing nature and early onset of her left wrist symptoms, as documented in numerous post-service treatment records.  It also omits any discussion of the relatively short period of time between the Veteran's discharge from active duty service and the subsequent x-ray images that document degenerative changes in the Veteran's left wrist.  These omissions reduce the probative weight that can be assigned to this competent medical opinion.

Although the record does not indicate that the Veteran possesses the medical knowledge, training, or experience to provide a diagnosis or opinion regarding the etiology of any current left wrist disability, she has provided competent and credible statements indicating that she has continued to experience left wrist symptoms during service and that these symptoms have continued after service.  The record also contains in-service evidence of complaints and treatment for symptoms that the Veteran has continued to describe in post-service treatment records.  Post-service treatment records also include x-ray images that were taken shortly after the Veteran's discharge from service that document degenerative changes in the Veteran's left wrist.  Balanced against the negative nexus opinion described above, the Board finds that the evidence is at least in equipoise regarding whether or not the Veteran's current left wrist symptoms and degenerative changes are etiologically related to her active duty service or have continued since service.  Resolving all reasonable doubt in the Veteran's favor, the Board therefore finds that the criteria for service connection for degenerative changes of the left wrist have been met.

Back and Bilateral Hips

As was the case with the Veteran's left wrist disability, service treatment records document in-service symptoms of both low back and hip symptoms.  For instance, a treatment note from as early as May 1986 includes complaints of right posterior hip pain with movement and the clinical presentation of a gait disturbance.  At htat time, the Veteran was assessed with a mild muscle strain.  By July 1992, the Veteran reported lower back pain despite denying lifting any heavy objects and had positive tenderness to palpation in the right lateral paraspinous region.  She was assessed at that time with musculoligamentous back pain.  Shortly before her separation, the Veteran completed a report of medical history form and attended a medical examination.  Although she did not present with any clinical abnormalities, the Veteran indicated that she had a history of back spasms that had begun after her cesarean section procedure in August 2005.  

The Veteran was afforded a VA medical examination in April 2007 relating to these conditions to determine the nature and etiology of any current back or hip disability.  The Veteran was ultimately diagnosed with a lumbar strain and a bilateral hip strain.  As such, the Board is satisfied that there is competent and probative evidence of a current back and hip disability and in-service symptoms relating to these conditions.  

The Board also notes that, although the Veteran does not have the medical experience or knowledge to provide a competent opinion regarding the nature or etiology of any current disability in these joints, she is competent to provide a medical history regarding the nature, progression, frequency, and onset of the observable symptoms of pain, tightness, radiation, or discomfort in these joints.  Notably, as was the case with the Veteran's left wrist disability, her reports of her back and hip symptoms have been relatively consistent.  Like her left wrist disability, the Veteran sought treatment for hip and back pain shortly after her retirement from active duty service.  

The record indicates that the Veteran sought treatment in June 2008 for symptoms of low back pain that was on and off since the 1980s that also went into both hips.  At a follow-up visit the following month, the Veteran reported sacroiliac joint pain for three years that was described as postpartum pain.  At another post-service treatment visit in August 2008, the Veteran reported increased pain in her low back for about four years, noting that she had engaged in a lot of lifting on active duty without specific injury, but stating that her pain was constant after giving birth to her second child four year prior.  

The Board notes that the timeline of symptoms the Veteran described to these treating clinicians largely mirrors the sequence of events she has reported in the course of the instant appeal.  For instance, at her July 2009 Board hearing, the Veteran indicated that she had back and hip pain while performing physically demanding duties as an airman shortly after she enlisted with the U.S. Navy.  However, she indicated that her symptoms were aggravated in the last three years she was on active duty after she began having children.  The Board notes that the consistency of the Veteran's lay statements with respect to the onset, frequency, and progression of her hip and back pain enhances the probative weight that can be given to this competent and credible evidence.  

The Veteran was afforded a VA medical examination with respect to these conditions in December 2009.  At that time, the Veteran again reported pain that was "on and off" since 1986 but which became significantly worse after the Veteran underwent a cesarean section procedure while on active duty.  This clinician provided diagnoses of lumbosacral strain and bilateral trochanteric bursitis.  However, this VA examiner ultimately opined that it was less likely than not that these disabilities were incurred in or aggravated by the Veteran's active duty service.  The examiner acknowledged that there were isolated reports of in-service hip and back pain, but noted that this evidence did not necessarily indicate the presence of a chronic ongoing problem with her back or hips.  Accordingly, the examiner indicated there was a lack of clinical evidence to support the claim that either was incurred in or aggravated by service.  

Although the December 2009 VA examiner is competent to provide this etiological opinion, the Board notes that it does not adequately address the competent, credible, and probative statements by the Veteran that she has continued to experience back and hip pain both during and after service that was exacerbated by the birth of her children.  As indicated above, the Veteran has repeatedly described this lay report of medical history to multiple clinical providers shortly after her separation from service.  As the Court noted in its Memorandum Decision, the Board also observes that the December 2009 VA examiner reported that the clinical evidence does not necessarily indicate the presence of a chronic hip or back condition.  However, this statement indicates that the evidence also does not necessarily rule out the presence of such a chronic hip or back condition.  

Ultimately, taken into consideration with the Veteran's competent and credible statements regarding the onset and progression of her back and bilateral hip symptoms, the Board finds that the balance of competent, credible, and probative evidence regarding whether or not the Veteran's current bilateral hip and back disabilities are etiologically related to her active duty service or have continued since service is at least in equipoise.  Resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for a bilateral hip strain and a lumbar strain have been met.


ORDER

Entitlement to service connection for degenerative disease of the left wrist is granted.

Entitlement to service connection for a lumbar strain is granted.

Entitlement to service connection for a bilateral hip strain is granted.




____________________________________________

Lesley A. Rein
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs

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