ARTHRITIS

Summary

The Veteran, who served from June 1977 to July 1977, appeals the denial of service connection for right and left hand arthritis. The Veteran claims these conditions are due to reactive arthritis (formerly Reiter's syndrome), for which he is already service-connected for his ankles and spine. The Board reviewed various medical opinions, including those from the Veteran's treating rheumatologist, Dr. N., and multiple VA examiners. The Veteran's treating rheumatologist opined that the reactive arthritis involved the hands and that failure to treat it earlier likely exacerbated the condition. The Board found Dr. N.'s opinion more persuasive than the negative VA opinions, noting that the VA examiners were not rheumatologists and did not adequately explain why degenerative changes in the hands were not indicative of reactive arthritis, despite the Veteran's history of dactylitis and positive HLS-B27 antigen. The Board found the March 2023 and December 2023 VA opinions, which gave due consideration to the treating physician's records and the Veteran's statements, to be more probative. Consequently, service connection for right and left hand arthritis was granted. The case was remanded for further development regarding the Veteran's left ankle reactive arthritis, as updated VA treatment records and VistA images were missing from the claims file.

Rationale

Service connection for right hand arthritis is warranted.; Evidence supports finding that right hand arthritis is part of reactive arthritis with onset during service.; Favorable opinions from treating rheumatologist and VA examiners given greater weight.

Full Decision Text

Citation Nr: 26004345
Decision Date: 04/08/26	Archive Date: 04/08/26

DOCKET NO. 17-00 262
DATE: April 8, 2026

ORDER

Entitlement to service connection for right hand arthritis is granted.

Entitlement to service connection for left hand arthritis is granted.

REMANDED

Entitlement to an initial rating in excess of 20 percent for reactive arthritis of the left ankle is remanded.

FINDINGS OF FACT

1. The evidence supports finding that the Veteran's right hand arthritis is caused by reactive arthritis that occurred during his active duty service.

2. The evidence supports finding that the Veteran's left hand arthritis is caused by reactive arthritis that occurred during his active duty service.

CONCLUSIONS OF LAW

1. The criteria for service connection for right hand arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for left hand arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty service from June 1977 to July 1977.

These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) in September 2014.

In a November 2016 rating decision, the RO granted an increased initial rating of 20 percent for the Veteran's left ankle disability.

The Veteran testified before the undersigned Veterans Law Judge at a Board hearing in June 2021. A copy of the hearing transcript has been reviewed and associated with the claims file.

These matters were previously before the Board in February 2022 and June 2022, and they were remanded both times for development.

Following the June 2022 remand, the RO granted service connection for kidney disease in a December 2023 rating decision and granted service connection for disabilities of the cervical spine, thoracolumbar spine, and left and right knees in a February 2024 rating decision. The grants of service connection constitute a full award of benefits sought on appeal with respect to the claims of service connection for disabilities of the cervical and thoracolumbar spine and left and right knees. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). The record currently available to the Board contains no indication that the Veteran has initiated an appeal with respect to the initial ratings or effective dates assigned. Id. (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Thus, these issues are not in appellate status at this juncture.

1. Entitlement to service connection for right hand arthritis

2. Entitlement to service connection for left hand arthritis

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

When evaluating the evidence of record, the Board must assess the credibility and probative value of the evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). 

A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). If "the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise) the claimant receives the benefit of the doubt." Id.? 

The Veteran has claimed entitlement to service connection for disabilities of the left and right hands. He asserts that his hand disabilities are due to reactive arthritis, previously known as Re
. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). 

A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). If "the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise) the claimant receives the benefit of the doubt." Id.? 

The Veteran has claimed entitlement to service connection for disabilities of the left and right hands. He asserts that his hand disabilities are due to reactive arthritis, previously known as Reiter's syndrome. The Veteran is currently service-connected for Reiter's syndrome of the left and right ankles, cervical spondylosis, and ankylosing spondylitis of the thoracolumbar spine. The February 2024 rating decision found that the Veteran had Reiter's syndrome in the left ankle during service in 1977. Thus, the evidence is sufficient to find that the Veteran did have Reiter's syndrome during his active service.

The Veteran's medical records include a July 1979 physician's statement indicating that he had a recent flare of joint pain and swelling. The findings mainly focused on the feet and ankles but also indicated swelling in the left and right metacarpophalangeal (MCP) joints. The Veteran was diagnosed with Reiter's disease.

An April 2004 private medical record indicates that the Veteran had a history of Reiter's syndrome and exhibited a lot of chronic pain behaviors. Swan-necking of the left long finger was noted. The Veteran's private medical records also indicate swelling, stiffness, and synovial thickening in the hands and MCP joints in December 2004 and January 2005.

The Veteran underwent a VA hand examination in September 2014, wherein the examiner indicated a diagnosis of degenerative arthritis in the left index finger only. The Veteran reported that he was diagnosed with Reiter's syndrome in 1977 and experienced flare-ups in the 1990s characterized by swelling and pain in both hands. He reported that he was treated for the flare-ups and the pain and swelling subsided, but he indicated continued swelling in both hands. The examiner opined that the Veteran's left index finger arthritis is less likely than not caused by his left ankle arthritis. The examiner noted that the Veteran's records show previous pain and swelling in the hands due to Reiter's syndrome, but the current findings were consistent with a degenerative joint condition. The examiner also opined that the Veteran's hand disabilities were less likely than not aggravated by his left ankle disability, as the evidence showed no evidence of aggravation. 

A February 2015 private treatment record indicates that the Veteran has suffered from spondylarthritis for the last 37 years and that his symptoms started with pain and swelling of the toes with progressive involvement affecting different joints. The treating physician expressed their belief that that the Veteran has had spondylarthritis over the last 37 years and that sometimes x-ray changes take time to develop. Considering the Veteran's sausage digits in the past and positive HLS-B27 antigen, the physician believed his symptoms have progressed to their current state. A March 2015 treatment record describes the fingers as "pudgy." The Veteran submitted an internet article discussing dactylitis, or "sausage finger/toe," in June 2021. The article indicates that dactylitis, where localized painful swelling causes digits to look like sausages, is most often seen in patients with inflammatory psoriatic or rheumatoid arthritis. MERRIAM-WEBSTER defines "pudgy" as "being short and plump." See https://www.merriam-webster.com/dictionary/pudgy (last accessed March 11, 2026). Accordingly, while the Board cannot make a medical determination, the evidence indicates that the Veteran's pudgy fingers could be indicative of dactylitis.

The Veteran submitted an internet article on reactive arthritis in December 2016. The article indicates that reactive arthritis may come on quickly and severely or more slowly, with sudden remissions or recurrences. It states that reactive arthritis usually affects the fingers, toes, ankles, hips, and knee joints. Additionally, the article states that x-rays of the joints other than the back do not usually reveal any abnormalities unless the patient has had recurrent episodes

The Veteran underwent another VA hand examination in March 2022, wherein the examiner confirmed a diagnosis of degenerative arthritis, other than posttraumatic, in both hands. The examiner opined that the Veteran's hand arthritis is less likely than not related to his active duty service. The examiner stated that current x-ray findings revealed degenerative arthritic changes and that it
2016. The article indicates that reactive arthritis may come on quickly and severely or more slowly, with sudden remissions or recurrences. It states that reactive arthritis usually affects the fingers, toes, ankles, hips, and knee joints. Additionally, the article states that x-rays of the joints other than the back do not usually reveal any abnormalities unless the patient has had recurrent episodes

The Veteran underwent another VA hand examination in March 2022, wherein the examiner confirmed a diagnosis of degenerative arthritis, other than posttraumatic, in both hands. The examiner opined that the Veteran's hand arthritis is less likely than not related to his active duty service. The examiner stated that current x-ray findings revealed degenerative arthritic changes and that it is unclear from the records whether the Veteran's hand disability is due to Reiter's syndrome which had become chronic. The examiner also stated that it is his clinical impression that the Veteran's Reiter's syndrome (now known as reactive arthritis) continues to be active. He indicated that the reactive arthritis had been chronic for a long time and clinically appears on radiographic examination as degenerative changes in both feet and ankles. However, the examiner did not explain why degenerative changes in the feet and ankles were indicative of reactive arthritis but degenerative changes in the hands do not indicate that same.

The Veteran submitted a non-degenerative arthritis disability benefits questionnaire completed by A.N., MD, the Veteran's treating rheumatologist, in April 2022. Dr. N. indicated that the Veteran's Reiter's syndrome caused significant pain in multiple joints, including the hands. In an accompanying letter, Dr. N. stated that the Veteran's Reiter's syndrome went untreated until 1985 because the Veteran did not have private medical insurance and was unaware of VA medical care at the time. Dr. N. stated that the failure to provide follow-up treatment after the initial diagnosis of Reiter's syndrome likely exacerbated the arthritic condition throughout the Veteran's body.

A VA addendum medical opinion was obtained in March 2023, wherein the examiner opined that the Veteran's hand arthritis is at least as likely as not related to his active service. The examiner noted the diagnosis of Reiter's syndrome in 1977 and indicated that the Veteran's rheumatologist noted that his Reiter's syndrome involved the left and right hands and fingers. However, the examiner also issued separate medical opinions stating that the Veteran's left and right hand arthritis is less likely than not related to his active service because reactive arthritis involving the right hand was not symptomatic until 1979, two years after the Veteran's discharge, and his left hand was not symptomatic until 1994. The Board notes that the examiner described the Veteran's arthritis as reactive in both hands. 

The same VA examiner issued another medical opinion in December 2023, opining that the Veteran's left and right hand arthritis is at least as likely as not related to his active service, stating that his hand disability is due to Reiter's syndrome, or reactive arthritis, which began in service. The examiner issued another medical opinion in February 2024, essentially reiterating her prior opinion. 

A different VA examiner issued a medical opinion relating to the Veteran's cervical spine disability in February 2024, in which he stated that degenerative changes shown in the cervical spine are consistent with reactive arthritis. The Board again notes that degenerative changes were also shown in both hands, but no examiner has indicated why the degenerative changes in the hands are not indicative of reactive arthritis. 

The Veteran underwent another VA hand examination in April 2024. The examiner opined that the Veteran's left and right hand arthritis is less likely than not related to his active service. He indicated that the Veteran reported that his hands became symptomatic in the 1980s and were diagnosed as having reactive arthritis in the 1990s, but the examiner could not find evidence of such in the medical records. The examiner stated that reactive arthritis occurs because of infection and that there is no documented evidence that the Veteran's hands were affected by foot cellulitis in 1977 or became symptomatic in the subsequent years. He stated that the current left and right hand arthritis was diagnosed more than 40 years after the initial infection and that there is insufficient objective evidence to associate the Veteran's hand arthritis as reactive arthritis associated with the initial infection in 1977.

A VA non-degenerative arthritis examination conducted in April 2024 indicates only the left ankle being involved with the Veteran's reactive arthritis. However, in the section discussing the Veteran's medical history, the examiner stated that the Veteran's reactive arthritis affects the left and right ankles, knees, shoulders, fingers, and feet.

After considering the relevant evidence, the Board finds that service connection for arthritis of the left and right hands is warranted. In this regard, the evidence supports finding that the Veteran's right and left hand arthritis is
 current left and right hand arthritis was diagnosed more than 40 years after the initial infection and that there is insufficient objective evidence to associate the Veteran's hand arthritis as reactive arthritis associated with the initial infection in 1977.

A VA non-degenerative arthritis examination conducted in April 2024 indicates only the left ankle being involved with the Veteran's reactive arthritis. However, in the section discussing the Veteran's medical history, the examiner stated that the Veteran's reactive arthritis affects the left and right ankles, knees, shoulders, fingers, and feet.

After considering the relevant evidence, the Board finds that service connection for arthritis of the left and right hands is warranted. In this regard, the evidence supports finding that the Veteran's right and left hand arthritis is part of his reactive arthritis or Reiter's syndrome, which had its onset during active service. This is supported by the March 2023 and December 2023 VA medical opinions, as well as the April 2022 disability benefits questionnaire and statement from the Veteran's rheumatologist. As the Veteran's treating physician and a specialist in rheumatology, Dr. N. is in the best position to opine on the nature and etiology of the Veteran's reactive arthritis. Dr. N. indicated that the Veteran's reactive arthritis involved both hands. 

The Board notes that none of the VA examiners who have issued opinions on this matter are rheumatologists. The negative VA medical opinions of record do not adequately consider Dr. N.'s records or the Veteran's statements. Additionally, they stated that the degenerative changes shown in x-rays do not indicate reactive arthritis without adequately explaining the basis for this conclusion. The March 2023 and December 2023 medical opinions give due consideration to Dr. N.'s records and to the Veteran's own statements regarding the history of his symptoms and disability, and the Board assigns greater evidentiary weight to these opinions than to the negative VA medical opinions. In summary, the evidence supports finding that the Veteran's right and left hand arthritis is reactive arthritis which began during the Veteran's active service, and the criteria for service connection for left and right hand arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS FOR REMAND

Entitlement to an initial rating in excess of 20 percent for reactive arthritis of the left ankle is remanded.

VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159.

VA has a duty to obtain VA treatment records, regardless of their relevance to the present claim, unless there is no reasonable possibility that such assistance would aid in substantiating the claim. Jones v. Wilkie, 918 F.3d 922, 926 (Fed. Cir. 2019); Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016).

The Veteran is currently in receipt of an initial 20 percent rating for reactive arthritis (formerly Reiter's syndrome) of the left ankle. He asserts that he is entitled to a higher rating. 

The Veteran's VA treatment records indicate that there are VistA images associated with his VA medical care. These records have not been added to the claims file, constituting pre-decisional error. In accordance with the duty to assist, the matter must be remanded to add all VistA images associated with the Veteran's VA medical treatment to the claims file.

The matter is REMANDED for the following actions:

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1. Obtain and associate with the claims file the Veteran's updated VA treatment records, from April 2024 to the present.

2. After completing #1, obtain and associate with the claims file all VistA images associated with the Veteran's VA treatment records.

 

 

Eric S. Leboff

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Pratt

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.