BONE NEOPLASM BENIGN

H.M. WALKER · 2025 · Case ID: 25007525

DENIED

Summary

The veteran, who served from June 1967 to March 1970, appeals the denial of service connection for a bilateral hand disorder and bilateral upper extremity radiculopathy. The veteran claimed these conditions were due to herbicide exposure in Vietnam, or alternatively, proximately due to or aggravated by his service-connected degenerative disc disease and osteoarthritis. The Board acknowledged the veteran's current diagnoses of Dupuytren's contracture, osteoarthritis, arthropathy, and radiculopathy, but found the evidence did not support a service connection. Multiple VA medical opinions, including recent ones from November 2024 and February/March 2025, concluded that the claimed hand disorders and radiculopathy were less likely than not related to service, herbicide exposure, or other toxic exposures. These opinions cited the lack of in-service complaints or diagnoses, the absence of chronicity, the role of advanced age, obesity, smoking, and genetic predisposition as primary risk factors for the degenerative conditions, and the distinct etiologies of the claimed conditions from service-connected disabilities. The Board found these opinions probative and uncontroverted by competent medical evidence. Therefore, service connection for the bilateral hand disorder and bilateral upper extremity radiculopathy was denied.

Rationale

Lack of in-service documentation for claimed disorders; No evidence of chronicity or in-service aggravation; Risk factors outside service outweigh potential exposure factors

Special Benefit

NO SPECIAL BENEFIT

Docket No.

09-27 535

Full Decision Text

Citation Nr: 25007525
Decision Date: 06/04/25 Archive Date: 06/04/25

DOCKET NO. 09-27 535
DATE: June 4, 2025

ORDER

Entitlement to service connection for a bilateral hand disorder (other than carpal tunnel syndrome (CTS)), including numbness, arthritis, bilateral Dupuytren's contracture, and other specified forms of arthropathy, is denied.

Entitlement to service connection for bilateral upper extremity radiculopathy is denied.

FINDINGS OF FACT

1. The evidence of record persuasively weighs against finding that a bilateral hand disorder began during active service, or is otherwise related to an in-service injury, event, or disease or developed secondary to a service-connected disability.

2. The evidence of record persuasively weighs against finding that bilateral upper extremity radiculopathy began during active service, or is otherwise related to an in-service injury, event, or disease or developed secondary to a service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for a bilateral hand disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for bilateral upper extremity radiculopathy are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1967 to March 1970.

This case is on appeal from a February 2008 rating decision.

In May 2018, May 2021, September 2021, February 2022, July 2022, and February 2023, the Board remanded the matters for additional development. In February 2023, the Board re-characterized the Veteran's issues on appeal as characterized above. The Board also granted service connection for bilateral CTS.

In April 2024 and February 2025, the Board remanded for additional development, to include to obtain new VA medical opinions. The requested opinions have since been obtained and there has been substantial compliance with the remand directives.

The Board notes that the Veteran has had a total disability rating based on individual unemployability (TDIU) effective from January 2007.

Service Connection

1. Entitlement to service connection for a bilateral hand disorder is denied.

2. Entitlement to service connection for bilateral upper extremity radiculopathy is denied.

The Veteran has claimed to have a bilateral hand disorder and bilateral upper extremity radiculopathy due to his active-duty service, to include his exposure to herbicides while serving in the Republic of Vietnam. In his August 2008 notice of disagreement (NOD), the Veteran specifically alleged that his numbness of the hands was caused by his herbicide agent exposure. He has also claimed, alternatively, that his numbness of the hands may be proximately due to, or aggravated by, his generalized osteoarthritis and/or his service-connected degenerative disc disease (DDD) of the thoracolumbar spine. As previously noted, the Veteran has already been granted service connection for CTS of the right and left upper extremities.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Alternatively, service connection may be granted for a disability that is due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310.

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Alternatively, the question for the Board is whether the Veteran has a current disability that is due to or the result of, or is/was aggravated by a service-connected disability

The Veteran had multiple diagnoses of the hands (other than CTS) that include bilateral Dup
.3d 1163, 1166 -67 (Fed. Cir. 2004).

Alternatively, service connection may be granted for a disability that is due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310.

The Veteran had multiple diagnoses of the hands (other than CTS) that include bilateral Dupuytren's contracture, bilateral osteoarthritis, and other specified forms of arthropathy, per a May 2022 VA examination. That VA examiner also diagnosed the Veteran with radiculopathy of the bilateral upper extremities, associated with cervical spine IVDS with degenerative disc disease (DDD).

The Board concludes that although the Veteran has current diagnoses related to the claimed disorders, the evidence of record persuasively weighs against finding that the Veteran's diagnosed disorders began during service or are otherwise related to an in-service injury, event, or disease or developed secondary or was aggravated by a service-connected disability.

The service treatment records did not generally show treatment for the diagnosed disorders. Such records do, however, show treatment for right wrist and arm complaints. A March 1969 record showed decreased grip strength of the right hand and a February 1970 Report of Medical History at separation noting swollen or painful joints and broken bones.

Following his 1970 separation from service, the record is silent for complaints of, or treatment for, the claimed disorders for decades. A March 2002 VA medical record indicated bilateral hand numbness, likely (already service-connected) CTS. An October 2004 VA medical record indicated numbness/tingling for the hands and arms for 10 years.

The Board notes that in the March 2021 Board remand, the Board had found that the October 2019 VA medical opinion (and thus the subsequent July 2020 VA medical opinion) was inadequate and afforded little probative value to the opinion provided at that time.

In September 2021, the Board found that the August 2021 VA medical opinion was inadequate and that the claims, as they were then characterized, were inextricably intertwined.

In February 2022, the Board found that none of the VA examinations addressed the Veteran's contentions regarding herbicide agent exposure or his report of swollen, painful joints in his February 1970 separation report of medical history. The Board remanded to fully address these matters.

In July 2022, the Board found that the May 2022 VA examiner, had provided an inadequate opinion regarding herbicide exposure and that the February 1970 report of "swollen painful joints" had not been mentioned, though the Board had previously directed its consideration.

In February 2023, the Board granted service connection for bilateral CTS and remanded the current claims. The Board found that the October 2022 VA examination did not address the Veteran's service treatment records reflecting upper extremity symptoms, to include right arm pain in May 1969, his duties of a clerk typist in Vietnam, and/or the Veteran's lay statements, including November 1968 and May 1969 notations of upper extremity injuries and pain in the upper extremity making it difficult to write. The Board remanded for a new VA medical opinion.

In an April 2024 Board remand, the Board again found that a new VA opinion was warranted. For the bilateral upper extremities claim, although a new VA medical opinion had been obtained in March 2023, the VA medical opinion provider had incorrectly found that the Veteran did not have bilateral upper extremity radiculopathy, based on an October 2019 VA examination finding of only CTS. The Board noted, however, that an October 2019 VA examination for the neck had diagnosed cervical radiculopathy and a May 2022 VA examination had diagnosed right and left upper extremity radiculopathy related to (nonservice-connected) cervical spine diagnoses, in addition to CTS. For the bilateral hand disorder claim, the March 2023 VA medical opinion, though addressing osteoarthritis, did not appear to address the previously diagnosed hand disorders of bilateral Dupuytren's contracture and other specified forms of arthropathy. The Board found that all the Veteran's hand diagnoses needed to be addressed. For all the claims, the Board also found that a VA medical opinion was necessary to fully address the PACT Act.

Most recently, in a February 2025 BVA
neck had diagnosed cervical radiculopathy and a May 2022 VA examination had diagnosed right and left upper extremity radiculopathy related to (nonservice-connected) cervical spine diagnoses, in addition to CTS. For the bilateral hand disorder claim, the March 2023 VA medical opinion, though addressing osteoarthritis, did not appear to address the previously diagnosed hand disorders of bilateral Dupuytren's contracture and other specified forms of arthropathy. The Board found that all the Veteran's hand diagnoses needed to be addressed. For all the claims, the Board also found that a VA medical opinion was necessary to fully address the PACT Act.

Most recently, in a February 2025 BVA remand, for the right upper extremity radiculopathy claim, the Board found that the November 2024 VA examiner had used a clear and unmistakable error (CUE) standard for the secondary service connection aggravation opinions and that a new VA medical opinion was necessary for the aggravation opinion. For the bilateral hand disorder claim, the Board found that November 2024 VA medical opinions did not address the previously diagnosed disorders, other than osteoarthritis. The Board requested a new VA medical opinion to clarify whether the Veteran had paresthesias of the hands found by the March 2023 VA medical opinion provider

The Board previously found that the March 2023 VA medical opinion indicated that the Veteran has paresthesia from to the Veteran's service-connected CTS but was unclear as to whether this is a separate disorder or is already considered part of CTS. A new VA medical opinion to clarify that matter was thus ordered. The November 2024 VA medical opinion found that the paresthesias of the hands identified in the March 2023 VA medical opinion was most likely related to the Veteran's service-connected CTS. The VA medical opinion provider, however, further found that the Veteran's Dupuytren's contracture and bilateral hand osteoarthritis, could also contribute to similar symptoms. Given the overlapping nature of symptoms associated with CTS, Dupuytren's contracture, and osteoarthritis, the paresthesias may not be an entirely separate diagnosis but rather a multifactorial issue where multiple conditions contribute to the Veteran's hand symptoms, and further medical evaluation may be necessary to determine the specific contributions of each condition to the Veteran's symptoms.

The Board notes that although it found that new VA medical opinions were necessary in the April 2024 the February 2025 Board remands, the Board did not find that the VA medical opinions starting from March 2023 were wholly inadequate or that the October 2022 VA medical opinion regarding claimed exposure was not adequate. The Board did not discount the March 2023 VA medical opinion addressing osteoarthritis of the hands but found that a VA medical opinion was necessary to also address the previously diagnosed hand disorders of bilateral Dupuytren's contracture and other specified forms of arthropathy.

In February 2025, the Board also only found that a new VA medical opinion was necessary for the bilateral upper extremities claims regarding aggravation, to address the diagnosed bilateral hand disorders (other than osteoarthritis), and to clarify whether the Veteran had a hand diagnosis of paresthesia separate from the already service-connected CTS. As such, the Board finds that the VA medical opinions discussed hereafter to be probative to the extent discussed for the claimed disorder. Moreover, the hereafter discussed examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examinations and opinions regarding the issues decided herein has been met.

To the extent that the Veteran has claimed that service connection is due to his toxic exposure risk activity (TERA) or herbicide agent and/or non-ionizing radiation exposure, August and September 2023 TERA memorandums have found that the Veteran has been exposed to herbicide agent and non-ionizing radiation.

Various VA medical opinions addressed the question of whether the claimed disorders developed due to TERA exposure.

In October 2022, a VA medical opinion provider found that the Veteran's claimed hand numbness and bilateral upper extremity radiculopathy was less likely than not caused by his service, to include his herbicide agent exposure in service. The examiner found that despite the Veteran's service duties, there was no documentation of numbness of left hand or left upper extremity problems in service or the immediate post-separation period. The Veteran's February 1970 complaint of "swollen painful joints" does not refer to numbness/tingling/weakness which is often seen in radiculopathy and the claimed condition would not present with "swollen or painful" joints. There was no evidence to objectively associate the condition with the service or exposure to herbicides and doing so would be entirely speculative for the hands and regarding radiculopathy. Radiculopathy involves nerve root irritation or impingement at the cervical vertebra level. The examiner found no evidence of any kind that such damage has been objectively correlated to exposure to herbicides in medical literature or the claims file. The examiner could not speculatively link this complaint with the service duties or herbicide exposure. Radiculopathy involved nerve root irritation or impingement at the cervical vertebra level. The examiner found no evidence of any kind that such damage to have been objectively correlated to exposure to herbicides in medical literature or the claims file.

A March 2023 VA examiner further found, regarding bilateral upper extremities claims, that the claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness, specifically to non-ionizing radiation exposure. The examiner found that there were no medical literatures that supported direct causal relationship of exposure to non-ionizing radiation or presumed exposure to herbicide agents during service in Vietnam in the development of neuropathy.

Regarding the claim for service connection for a hand disorder, the March 2023 VA examination found that the claimed disorders was less likely than not incurred in or caused by the claimed in-service injury, event, or illness - considering exposure to non-ionizing radiation. The examiner noted that the Veteran had moderate degenerative changes of the right hand, per a May 2022 X-ray, taken years after separation from service. The examiner found that exposure to non-ionizing radiation did not have direct causal relationship in the development of arthritis that is supported by medical literatures.

In November 2024, a new VA medical opinion was obtained to address the Veteran's TERA exposure for both his bilateral upper extremity radiculopathy and bilateral hand disorder claims.

The November 2024 VA examiner found that the Veteran's bilateral upper extremity radiculopathy and bilateral hand disorder osteoarthritis were less likely than not caused by the indicated TERA, after considering the total potential exposure through all applicable military deployments and the synergistic, combined effect of all toxic exposure risk activities of the Veteran, to include to Herbicide Agent - 2,3,7,8 - Tetrachlorodibenzodioxin (TCDD) and Non-ionizing radiation exposure in Vietnam, to include as due to his MOS as a systems repairman/microwave technician.

The November 2024 VA examiner found that radiculopathy was due to nerve root irritation and impingement from cervical pathology. It is a disturbance of nerve conduction that is due to structural pathology in the cervical vertebra. The examiner found no objective evidence that would attribute the condition to exposure. The job aids and literature did not allow for any such correlation.

The November 2024 VA examiner also found that hand osteoarthritis is a degenerative joint disease that involves the gradual breakdown of cartilage. The risk of developing hand included the Veteran's advanced age (78), obesity (BMI: 30.3), history of smoking, and repetitive hand activities have significantly increased his risk of developing hand osteoarthritis. The examiner found that the risk factors outside of military service far outweigh any potential factors related to the TERA. Furthermore, correlation to the suspected exposure is not objectively supported by the claims file, medical literature, or the job aids.

In a February 2025 VA TERA medical opinion, the VA examiner opined that all the Veteran's claimed hand condition(s) - including right Dupuytren's contracture, right osteoarthritis, and other specified forms of arthropathy were
of cartilage. The risk of developing hand included the Veteran's advanced age (78), obesity (BMI: 30.3), history of smoking, and repetitive hand activities have significantly increased his risk of developing hand osteoarthritis. The examiner found that the risk factors outside of military service far outweigh any potential factors related to the TERA. Furthermore, correlation to the suspected exposure is not objectively supported by the claims file, medical literature, or the job aids.

In a February 2025 VA TERA medical opinion, the VA examiner opined that all the Veteran's claimed hand condition(s) - including right Dupuytren's contracture, right osteoarthritis, and other specified forms of arthropathy were less likely than not caused by the indicated TERA. The examiner noted outside of service risk factors outside of military service: Advance age, smoking history and obesity. The examiner noted frequency and route of exposure, as well as duration, location, and activities involved for exposure. The examiner also noted a history of herbicide agent exposure.

The February 2025 TERA VA examiner found that the claimed Dupuytren's contracture and other specified forms of arthropathy condition were less likely than not caused by the indicated TERA, after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all TERA. The examiner noted that Dupuytren's contracture is a progressive fibroproliferative disorder, with common etiologies include genetic predisposition, particularly in individuals of Northern European descent; chronic microtrauma or repetitive hand strain, which may contribute to fibrotic changes in the palmar fascia; and systemic conditions such as diabetes mellitus, which has been associated with an increased risk of connective tissue disorders. Additional risk factors include advanced age, excessive alcohol consumption, and smoking. The examiner found no evidence in the claims file or job aid that Dupuytren's contracture is due to any exposure or cumulative exposure.

The February 2025 VA examiner further found that other specified forms of arthropathy encompass a broad category of joint disorders that do not fit under common diagnoses such as osteoarthritis or rheumatoid arthritis but still result in pain, swelling, and functional impairment. These conditions may arise from crystal-induced arthropathies, post-traumatic arthritis, infectious arthritis, or autoimmune-related arthropathies such as psoriatic or reactive arthritis. Possible causes included advanced age, metabolic disorders like hyperuricemia, chronic inflammatory conditions, genetic predisposition, repetitive joint stress, and lifestyle factors such as excessive alcohol use or poor diet. There was no documentation linking the development of other specified forms of arthropathy to military service, deployment, or exposure events, and no medical or scientific evidence indicates a relationship between this condition and TERA. The examiner found no evidence in the claims file or job aid that it was due to any exposure or cumulative exposure.

The Board finds that the most probative evidence of record indicates that the Veteran's claims bilateral upper extremity radiculopathy and bilateral hand disorder claims did not develop due to the Veteran's TERA exposure, to include herbicide agent and non-ionizing radiation exposure. There is no competent opinion to the contrary.

The Board will thus turn to the question of whether direct service connection for any of the claimed disorders.

For the bilateral hand disorder direct service connection claims, there are various relevant VA medical opinions of record.

The March 2023 VA examiner that the claimed left hand osteoarthritis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the medical records did not demonstrate existence of left hand condition during service and that he was noted to have moderate degenerative changes of the left hand in an x-ray dated May 2022, several years after separation from service.

In September 2023, an addendum medical opinion was obtained for the Veteran's Dupuytren's contracture. The examiner noted various medical records and found that although the Veteran had reported hand pain in 1969 and 1970, the symptoms incurred during service were acute were not conclusive of the currently diagnosed - Dupuytren's contracture. Therefore his Dupuytren's contracture was less likely than not incurred during service.

In a November 2024 VA medical opinion, for osteoarthritis of the hands, the examiner found that it was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted review of the claims file and specific records of interest but found no record of chronic or recurrent hand problems beginning in the service or immediate post-separation period. A nexus for service connection cannot be made at this time due to the missing
reported hand pain in 1969 and 1970, the symptoms incurred during service were acute were not conclusive of the currently diagnosed - Dupuytren's contracture. Therefore his Dupuytren's contracture was less likely than not incurred during service.

In a November 2024 VA medical opinion, for osteoarthritis of the hands, the examiner found that it was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted review of the claims file and specific records of interest but found no record of chronic or recurrent hand problems beginning in the service or immediate post-separation period. A nexus for service connection cannot be made at this time due to the missing elements of origin and chronicity of the current condition. The examiner explained that a disability which began in service or was caused by some event in service must be considered "chronic" before a nexus for service connection can be established. No permanent residual or chronic disability is shown by the service medical records or demonstrated by evidence immediately following discharge from the service. A nexus for service connection for the Right hand osteoarthritis condition cannot be made.

Additionally, a February 2025 VA examination opinion found that the Veteran's Dupuytren's contracture and other specified forms of arthropathy condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted reviewed the claims file, the lay statements, and the cited specific records of interest. The examiner found no record of chronic or recurrent hand problems beginning in the service, with no complaints of right hand pain in the service treatment records or immediate post-separation period. Although the service treatment records included to upper extremity issues, these records do not support a nexus between military service and the development of Dupuytren's contracture or arthropathy of the right hand.

The examiner noted that the May 1969 service treatment record documented left wrist pain, with an impression of "L wrist pain"-indicating that the symptoms reported at that time were specific to the left wrist, not the right hand. No mention of right-hand pain, contracture, or arthropathy was made, and no chronic condition was diagnosed. The focus on the left wrist suggests that the entry is not relevant to the claimed right-hand disability. The November 1968 record pertains to an optometry clinic visit, which does not provide any evidence of an injury or condition affecting the right hand or upper extremities. This entry does not support the Veteran's claim of an in-service right-hand injury or ongoing hand disability. The March 1969 service treatment record noted decreased grip strength in the right hand, but there is no indication of an underlying chronic condition or follow-up treatment for persistent symptoms. Grip strength can be affected by temporary factors such as muscle strain or fatigue, and in the absence of chronicity, this isolated finding does not establish a service-related right-hand disability. The February 1970 report of medical history at separation included the Veteran's report of swollen or painful joints and broken bones, but it does not specify the right hand, nor does the corresponding separation examination indicate a chronic right-hand condition.

The examiner further indicated that the Veteran's self-reported symptoms without objective findings do not establish a medically diagnosed disability. Also, the Veteran's duties as a clerk typist, which would have required repetitive hand use; however, no in-service medical records document treatment for repetitive stress injuries, trauma, or chronic hand problems related to this occupational duty.

The examiner also considered the prior VA examinations, including an August 1970 VA examination noted symptoms after radiation exposure, but there was no documented link between the reported exposure and Dupuytren's contracture or other arthropathy of the right hand. The October 2019 VA examination suggested a possible relationship between the Veteran's hand symptoms and generalized osteoarthritis, a degenerative condition commonly associated with age and systemic factors rather than an isolated in-service event. Dupuytren's contracture is a fibroproliferative disorder primarily associated with genetics, age, diabetes, and mechanical stress, but there is no medical evidence linking its onset to the Veteran's service. Osteoarthritis and other arthropathies are typically degenerative in nature, often developing over time due to aging and cumulative mechanical wear rather than as a direct result of in-service trauma.

Further, the examine acknowledged lay reports but they are not substantiated by contemporaneous medical documentation demonstrating a chronic right-hand condition. No right-hand diagnosis was made during service or in the years immediately following separation. A nexus for service connection cannot be made at this time due to the missing elements of origin and chronicity of the current conditions. The examiner explained that a disability which began in service or
associated with genetics, age, diabetes, and mechanical stress, but there is no medical evidence linking its onset to the Veteran's service. Osteoarthritis and other arthropathies are typically degenerative in nature, often developing over time due to aging and cumulative mechanical wear rather than as a direct result of in-service trauma.

Further, the examine acknowledged lay reports but they are not substantiated by contemporaneous medical documentation demonstrating a chronic right-hand condition. No right-hand diagnosis was made during service or in the years immediately following separation. A nexus for service connection cannot be made at this time due to the missing elements of origin and chronicity of the current conditions. The examiner explained that a disability which began in service or was caused by some event in service must be considered "chronic" before a nexus for service connection can be established. No permanent residual or chronic disability is shown by the service medical records or demonstrated by evidence immediately following discharge from the service. Therefore, the examiner opined that a nexus for service connection for the Dupuytren's contracture and other specified forms of arthropathy condition cannot be made.

Regarding the claimed bilateral upper extremity radiculopathy direct service connection claim, the VA medical opinions were similarly negative.

For the March 2023 VA medical opinion for bilateral upper extremity radiculopathy, as noted above, in April 2024 the Board found that a new VA medical opinion was necessary given that the March 2023 VA examiner had not considered the diagnosis of radiculopathy.

A new VA medical opinion for radiculopathy was obtained in November 2024. The examiner found that it was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted review of the claims file and cited specific records of interest but found no record of chronic or recurrent peripheral nerves problems beginning in the service or immediate post-separation period. The examiner indicated that a nexus for service connection cannot be made at this time due to the missing elements of origin and chronicity of the current condition as found in the exam. A disability which began in service or was caused by some event in service must be considered "chronic" before a nexus for service connection can be established. No permanent residual or chronic disability is shown by the service medical records or demonstrated by evidence immediately following discharge from the service. Therefore, the examiner indicated a nexus for service connection cannot be made.

The discussed VA examiner opinions on direct service connection for both the bilateral hand disorder and bilateral upper extremity radiculopathy found that the claimed disorders were each not at least as likely as not related to an in-service injury, event, or disease, with specific rationales for each claim. The examiners' opinions are probative, because each is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Thus, the most probative evidence of record does not support finding that service connection for bilateral upper extremity radiculopathy or a bilateral hand disorder is directly due to service. Again, the Veteran is already in receipt of service connection benefits for CTS is each upper extremity.

The Board will now turn to considering whether service connection would be warranted on a secondary basis.

For the bilateral hand disorder claims, the question of whether the hand disorders were caused or aggravated by service-connected disabilities was only fully addressed in the February and March 2025 VA medical opinions.

The February 2025 VA medical opinion provider found that the claimed bilateral hand disorder was less likely than not proximately due to or the result of or aggravated by the Veteran's service connected condition(s). The VA examiner also found that they were also not aggravated beyond its natural progression by the Veteran's service-connected disabilities. The examiner noted that Dupuytren's contracture is a fibroproliferative disorder affecting the palmar fascia, leading to progressive thickening and contracture of the fingers. The exact cause remains unclear, but it is strongly associated with genetic predisposition, as it is more common in individuals of Northern European descent. Additionally, age over 50, male sex, diabetes mellitus, chronic liver disease, alcohol use, and smoking are well-documented risk factors. The pathophysiology involves abnormal myofibroblast proliferation, increased collagen deposition, and altered signaling pathways, which drive fibrosis of the fascia. Importantly, the examiner noted that Dupuytren's contracture is not primarily a neurologic or joint disorder and does not result from nerve compression (such as carpal tunnel syndrome), arthritis, radiculopathy, or hypertension.

The examiner further elaborated that chronic hand trauma can be a contributing
unclear, but it is strongly associated with genetic predisposition, as it is more common in individuals of Northern European descent. Additionally, age over 50, male sex, diabetes mellitus, chronic liver disease, alcohol use, and smoking are well-documented risk factors. The pathophysiology involves abnormal myofibroblast proliferation, increased collagen deposition, and altered signaling pathways, which drive fibrosis of the fascia. Importantly, the examiner noted that Dupuytren's contracture is not primarily a neurologic or joint disorder and does not result from nerve compression (such as carpal tunnel syndrome), arthritis, radiculopathy, or hypertension.

The examiner further elaborated that chronic hand trauma can be a contributing factor, but there is insufficient evidence to establish a direct causal link between the claimed conditions and the development of Dupuytren's contracture. Furthermore, other specified forms of arthropathy is a broad term that includes degenerative, inflammatory, post-traumatic, and metabolic joint conditions. The most common cause of wrist arthropathy is osteoarthritis, which is typically associated with age-related cartilage degeneration, prior trauma, or repetitive stress. Other causes include autoimmune conditions (e.g., rheumatoid arthritis, psoriatic arthritis), metabolic disorders (e.g., calcium pyrophosphate deposition disease, hemochromatosis), and post-traumatic changes. The Veteran's documented conditions, including bilateral carpal tunnel syndrome, osteoarthritis, and radiculopathy, involve nerve compression, degenerative changes, or nerve-related pain but do not directly cause the fibroproliferative or inflammatory processes seen in Dupuytren's contracture or arthropathy. There was no evidence in the entire claims file of any "aggravation", nor any evidence "aggravation" has ever been objectively verified or any evidence to attribute "aggravation" of the disorders. The examiner found that determination of aggravation was not objectively supported. Furthermore, given the distinct etiologies of these conditions, it was less likely than not that the claimant's had disorders proximately due to or the result of the service-connected conditions.

Additionally, a March 2025 VA medical opinion provider found that the Veteran's hand disorders were less likely than not proximately due to or the result of or aggravated by the service-connected disabilities. The examiner noted medical record review. The VA examiner explained that Dupuytren's contracture is an abnormal thickening of tissues in the palm of the hand and the service-connected disabilities are anatomically or physiologically related to hand to cause abnormal thickening of tissues in the palm of the hand or arthritic changes to the joints of the hand. The service-connected disabilities were also not anatomically or physiologically related to the hands to aggravate the abnormal thickening of tissues in the palm of the hand or arthritic changes to the joints of the hand. The examiner also noted consideration of medical literature in reaching their opinion.

A March 2023 VA medical opinion similarly found, only specific to the Veteran's bilateral hand disorder of arthritis, that it was less likely than not caused or aggravated by the service-connected disabilities. The examiner found that a review of records did not demonstrate progression of the hand arthritis. Additionally, the examiner noted the service-connected disabilities do not anatomically affect the hands. The examiner further found that the service-connected disabilities did not have direct causal relationship in the development of arthritis in the hand, such that the arthritis was less likely than not proximately due to or the result of the service-connected disabilities.

Regarding the claim for service connection for the bilateral upper extremities as secondary to the service-connected disabilities, the Board had previously found that the March 2023 VA medical opinion was not adequate for the bilateral upper extremities secondary service connection claims. Subsequently new VA medical opinion was obtained in November 2024 (only to the left upper extremity).

The November 2024 VA medical opinion provider found that the claimed bilateral upper extremity radiculopathy was less likely than not proximately due to or the result of the Veteran's service connected condition. The examiner noted consideration of evidence. The examiner found the bilateral upper extremity radiculopathy occurs when degenerative changes in the cervical spine led to nerve root compression, causing pain, weakness, numbness, or tingling in the shoulders, arms, and hands. Over time, the cervical discs can lose height, dry out, or herniate, which may narrow the spaces where nerves exit the spine (foraminal stenosis). This compression can irritate the nerve roots, often resulting in radiating symptoms down the upper extremities.

The examiner highlighted that in the Veteran's claim, his advanced age (78), obesity (BMI: 30.3), and
the result of the Veteran's service connected condition. The examiner noted consideration of evidence. The examiner found the bilateral upper extremity radiculopathy occurs when degenerative changes in the cervical spine led to nerve root compression, causing pain, weakness, numbness, or tingling in the shoulders, arms, and hands. Over time, the cervical discs can lose height, dry out, or herniate, which may narrow the spaces where nerves exit the spine (foraminal stenosis). This compression can irritate the nerve roots, often resulting in radiating symptoms down the upper extremities.

The examiner highlighted that in the Veteran's claim, his advanced age (78), obesity (BMI: 30.3), and smoking history significant risk factors that contribute to the progression of cervical spine degeneration, increasing the likelihood of radiculopathy. Additional contributing factors, such as repetitive neck movements, poor posture, and a sedentary lifestyle, can further accelerate disc degeneration and nerve irritation, exacerbating the radiculopathy. The examiner found that it was unlikely that the Veteran's upper extremity radiculopathy was caused by the service-connected disabilities. The examiner found no supportive documentation in the claims file or noted evidence to support such a connection between the various service-connected disabilities and finding a connection without objective evidence would be entirely speculative.

In February 2025, the Board found that the November 2024 VA medical opinion was inadequate only to the extent that the VA examiner had used a CUE standard for the aggravation opinions.

In February and March 2025, new aggravation opinions for the bilateral upper radiculopathy claims were obtained.

In February 2025, the VA medical opinion provider found that the bilateral upper extremities were less likely than not aggravated beyond its natural progression by the Veteran's service connected bilateral CTS or other service-connected disabilities. The examiner explained that radiculopathy occurs when nerve roots emerging from the spinal cord become compressed or irritated, leading to pain, weakness, numbness, or tingling that radiates along the affected nerve pathway. Cervical radiculopathy, results from compression of nerve roots in the cervical spine, commonly due to degenerative conditions such as IVDS and DDD. The examiner noted the underlying cause of current upper extremity radiculopathy is cervical spine IVDS with DDD, which directly affects the cervical nerve roots. The Veteran's CTS was a distinct condition that affects the median nerve at the wrist, leading to symptoms localized to the hand and fingers. The examiner indicated that CTS does not originate from or impact the cervical spine and does not contribute to or aggravate cervical radiculopathy.

Similarly, the examiner found that the Veteran's other service-connected disabilities do not have a direct anatomical or biomechanical relationship with cervical radiculopathy. Hypertension, while a systemic condition, does not have a known direct pathophysiological mechanism for aggravating cervical radiculopathy beyond its natural course. While vascular issues can sometimes affect nerve function, there was no medical evidence suggesting that the Veteran's hypertension contributed to the worsening of cervical nerve root compression or radiculopathy. Additionally, the Veteran's advanced age is a well-established risk factor for degenerative spine conditions, including IVDS and DDD, which are the primary contributors to cervical radiculopathy. The examiner indicated that due to age and gravity, weight gaining, and weight bearing, the progressive degeneration is naturally expected to progress and to worsen. The examiner found no evidence of unnatural aggravation of the degeneration.

A March 2025 VA medical opinion provider also found that the bilateral upper extremity radiculopathy was less likely than not aggravated beyond its natural progression by the Veteran's service-connected disabilities. The examiner found such disorders were separate and unrelated conditions. The examiner indicated that upper radiculopathy is caused by impingement, compression, of the spinal roots/nerves causing pain, numbness and tingling symptoms. In this case, the upper radiculopathy impinges the cervical spine nerve roots resulting to upper extremity radicular symptom consistent with current diagnosis. The service-connected disabilities were not anatomically or physiologically related to upper radiculopathy and did aggravate the impingement of cervical spinal nerve roots.

The discussed various VA examiner opinions on secondary service connection for both the bilateral hand disorder and bilateral upper extremity radiculopathy found that the claimed disorders were each not at least as likely as not proximately due to or the result of the service-connected disabilities or aggravated by such disabilities. The discussed examiners' opinions are probative, because as they based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, supra.

The February 2025 VA
extremity radicular symptom consistent with current diagnosis. The service-connected disabilities were not anatomically or physiologically related to upper radiculopathy and did aggravate the impingement of cervical spinal nerve roots.

The February 2025 VA medical opinion also found that the Veteran's hand disorders, including Dupuytren's contracture, osteoarthritis, and other specified forms of arthropathy, present overlapping symptoms that complicate the differentiation of each condition's contribution to the overall hand impairment, and with the already service-connected CTS, and might not be entirely separable due to the interconnected nature of the conditions. Essentially, the Veteran's CTS sensory symptoms may be exacerbated and symptoms of disorders might not be entirely separable.

The Board notes that the Veteran is in receipt of a 40 percent disability rating for right upper extremity CTS and a 30 percent rating from left upper extremity CTS, rated under Diagnostic Code 8511, indicative of moderate, incomplete paralysis. There is no indication in the record that the ratings for right and left upper extremity CTS has been limited due to a differentiation of symptoms that may be at least partially based on the other nonservice-connected disorders of the hands. As such, the Board finds additional examination to attempt to differentiate the symptoms when the Veteran already receives the benefit of the doubt as to all the symptoms that may be related to CTS is not necessary.

To the extent that the Veteran believes the claimed disorders are the result of service or caused or aggravated by his service-connected disabilities. The Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, anatomical relationships, pathology, and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011).

Consequently, the Board gives more probative weight to the VA medical opinions discussed in the decision above.

The discussed VA examiners' respective opinions are also considered probative, as they are uncontroverted by any evidence of record, apart the Veteran's own implied assertions. See Black v. Brown, 10 Vet. App. 279, 284 (1997) (in determining the weight assigned to this evidence, the Board looks at factors such as the health care provider's knowledge and skill in analyzing the medical data). Further, absent such countervailing medical evidence, the Board itself is prohibited from exercising its own independent judgment in the Veteran's favor. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board may not exercise its own independent judgment to resolve medical questions).

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As the most probative evidence persuasively weighs against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). Entitlement to service connection for a bilateral hand disorder and for bilateral upper extremity radiculopathy is denied.

H.M. WALKER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Lindio

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.

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