Citation Nr: 1046071 Decision Date: 12/09/10 Archive Date: 12/20/10 DOCKET NO. 07-25 892 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for bilateral thoracic outlet syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Mecone, Associate Counsel INTRODUCTION The Veteran had active military service from October 1985 through February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. FINDING OF FACT The Veteran likely has bilateral thoracic outlet syndrome that began during active duty. CONCLUSION OF LAW The Veteran has bilateral thoracic outlet syndrome that is the result of disease or injury incurred during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION Because the Board is granting the Veteran's claim, there is no need to engage in any analysis with respect to whether the requirements of the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010)), have been satisfied with respect to the question of service connection. That matter is moot. Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). Further, it is not enough that an injury or disease occurred in service; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The Veteran contends that he is entitled to service connection for bilateral thoracic outlet syndrome. He reported experiencing numbness and tingling in his arms during service when his arms were raised above his shoulders, and noted that he continues to experience numbness and tingling when he raises his arms above his shoulders. Here, the service treatment records (STR's) contain several entries reflecting diagnoses of bilateral thoracic outlet syndrome. For example, a May 2002 entry reflected a diagnosis of thoracic outlet syndrome which was not problematic, and stated that the Veteran should avoid activities requiring prolonged overhead lifting. An April 2003 entry noted that the Veteran presented complaining of his arms falling asleep, and was told that it was a pinched nerve. The examiner noted that the Veteran had a prior diagnosis of thoracic outlet syndrome, and stated that the symptoms were still problematic, but the Veteran denied an evaluation for correctibility. The examiner noted that radial artery pulses were down with elevation of the arms, and gave an impression of thoracic outlet syndrome. An April 2003 entry noted that the Veteran presented complaining of numbness and tingling in both arms which was aggravated when he raised his arms over his head, and the impression provided was thoracic outlet syndrome or cervical radiculopathy, with the examiner scheduling testing to confirm the diagnosis. A June 2005 progress note reflected a diagnosis of thoracic outlet syndrome in addition to left cubital tunnel syndrome with no relief status post left ulnar nerve transposition surgery, and an October 2005 entry again reflected a diagnosis of thoracic outlet syndrome. Although in-service electrodiagnostic and nerve conduction studies did not find evidence of neurogenic thoracic outlet syndrome, (see May 2003 electrodiagnostic study and nerve conduction test), clinical examinations on several occasions reflected a diagnosis of this disability. Resolving reasonable doubt in the Veteran's favor, the Board finds that the record contains medical evidence of in-service incurrence of bilateral thoracic outlet syndrome. A few months after the Veteran's February 2006 discharge, he was afforded a QTC examination where the physician, R.T., M.D., again diagnosed bilateral thoracic outlet syndrome. See July 2006 QTC examination. Although a neurological examination of the upper extremities revealed that motor and sensory function were within normal limits, Dr. T. reported that radial artery pulses diminished with elevation of the arms, and noted that this was consistent with a diagnosis of thoracic outlet syndrome. Dr. T. noted that the symptoms of the Veteran's disability affected his ability to keep his hands above shoulder level for extended periods of time as his arms and fingers became numb and started to tingle after only a few minutes. Here, as noted above, the Veteran was diagnosed with thoracic outlet syndrome during service, as recently as October 2005, and he was diagnosed with the same disability-bilateral thoracic outlet syndrome five months after discharge in July 2006. Further, the Veteran has reported continuous symptoms related to his thoracic outlet syndrome from the time he was in service up until the present. Specifically, during his July 2006 QTC examination, the Veteran reported that he had been suffering from bilateral thoracic outlet syndrome for six years, with symptoms that included numbness and tingling from his shoulder down to his finger, most noticeably when he lifted his arms above his shoulders. Numbness and tingling are symptoms capable of lay observation, (see Layno v. Brown, 6 Vet. App. 465, 470 (1994)), and the medical evidence supports the Veteran's contention that he experienced symptoms related to his bilateral thoracic outlet syndrome during service and ever since discharge. As such, the Board finds that continuity of symptomatology of his disability has been established. The Board points out that an evaluation of the same disability impairment under another diagnostic code is pyramiding, which is to be avoided. See 38 C.F.R. § 4.14 (2010). The Veteran is currently service-connected for residuals of left ulnar nerve transposition surgery which was undertaken during service to relieve cubital tunnel syndrome. The symptoms of the Veteran's service-connected residuals of left ulnar surgery include tingling, numbness, and abnormal sensation from the left elbow to the left hand, and also pain that travels from the left elbow to the left hand. If the Veteran's symptoms of left arm tingling, numbness and abnormal sensation are evaluated as part of his service-connected ulnar nerve transposition surgery of the left arm, to also evaluate the same symptoms under another set of rating criteria would be pyramiding, which is prohibited by 38 C.F.R. § 4.14 (2010). See id. However, in this case, the Board finds that the medical evidence reveals that the symptomatology of the Veteran's bilateral thoracic outlet syndrome which includes numbness, tingling, anesthesia and bilateral arm weakness is not entirely duplicative of the symptomatology of the Veteran's service-connected left arm ulnar transposition surgery. Initially, the Board finds that although the Veteran suffers from numbness, tingling, abnormal sensation, weakness, and pain from his right shoulder down to his right hand, pyramiding is not a relevant issue as he is not currently service-connected for any nerve disability related to the right shoulder and arm. Further, resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's currently service-connected residuals of ulnar nerve transposition surgery of the left arm, evaluated as 10 percent disabling, does not preclude service connection for left upper extremity thoracic outlet syndrome. There is not sufficient medical evidence showing that the symptomatology and nerves involved in the Veteran's service- connected residuals of left ulnar nerve transposition surgery overlap with the symptomatology of his currently diagnosed left upper extremity thoracic outlet syndrome. In particular, the symptoms of the Veteran's thoracic outlet syndrome affect his shoulder down to his fingers, while the residuals of his left ulnar nerve transposition surgery only involve the portion of his arm from his left elbow to his hand. See July 2006 QTC examination. Further, the July 2006 QTC physician was specifically requested to list any residuals of the in-service left ulnar transposition surgery, and the physician listed only intermittent sharp elbow pain. After considering the medical evidence of record, the Board does not find that the regulations pertaining to pyramiding (see 38 C.F.R. § 4.14) preclude service connection for bilateral thoracic outlet syndrome. Based on the above analysis, and resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for bilateral thoracic outlet syndrome is granted. ORDER Service connection for bilateral thoracic outlet syndrome is granted. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs