Citation Nr: 0814190 Decision Date: 04/30/08 Archive Date: 05/08/08 DOCKET NO. 06-00 397 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an increased rating for service-connected metatarsalgia of the left foot, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for service-connected median mononeuropathy with osteoarthritis from fracture of the left wrist, currently evaluated as 20 percent disabling. REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Lawrence W. Klute, Associate Counsel INTRODUCTION The veteran served on active duty from November 1967 to June 1969 and from January 1982 to November 1990. Service in Vietnam is indicated by the evidence of record. This case comes before the Board on appeal from rating decisions rendered by the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan (the RO) in September 2004 and October 2005. Procedural history Service connection for fracture of the left wrist was granted in an October 1991 decision by the RO. By a June 1993 decision, the Board of Veterans' Appeals (Board) granted service connection for a left foot disorder, last classified as metatarsalgia. In its September 2004 rating decision, the RO granted an increased rating from 10 percent to 20 percent for the veteran's service-connected left writ disability, denominated as median mononeuropathy with osteoarthritis from fracture of the left wrist. The RO also denied a compensable rating for the veteran's service-connected metatarsalgia of the left foot. In its October 2005 decision, the RO granted an increased rating to 10 percent disabling for the veteran's service- connected metatarsalgia of the left foot. The veteran has not expressed satisfaction with that decision. In his December 2005 substantive appeal (VA Form 9), the veteran requested a personal hearing with a Veterans Law Judge at the RO. In January 2006 he changed his request to a Board hearing in Washington, D.C. However, by a February 2007 e-mail, the veteran withdrew his request for a hearing. Remanded issue The issue of entitlement to an increased rating for median mononeuropathy with osteoarthritis from fracture of the left wrist, currently evaluated as 20 percent disabling, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the VA Appeals Management Center (AMC) in Washington, D.C. Matters not on appeal In its September 2004 rating decision, the RO granted an increased rating, from 10 percent to 20 percent disabling, for the veteran's service-connected duodenal ulcer with hiatal hernia. The veteran has not disagreed with that decision. That matter is therefore not in appellate status and will be addressed no further herein. In a February 2007 informal hearing presentation, the veteran's representative contended that the veteran had been diagnosed with left foot talipes caves deformity, claw toe, and hammertoe deformity, all of which he contended should be considered for service connection on a direct basis or as secondary to the service-connected left foot metatarsalgia. These matters have not yet been developed and adjudicated by the RO, and they are accordingly referred to the RO for such further action as may be appropriate. See Godfrey v. Brown, 7 Vet. App. 398 (1995) [the Board does not have jurisdiction of issues not yet adjudicated by the RO]. FINDINGS OF FACT 1. The veteran's metatarsalgia of the left foot is manifested by pain mostly in the lateral side of the foot and a burning sensation on the sole of the foot, becomes moderate with excessive activity, is stabilized with use of a shoe insert for cushioning the sole, and flare-ups are alleviated to some degree by removal of the shoe and rest; the veteran does not use assistive devices to walk. 2. The evidence in this case does not show a marked interference with employment or frequent periods of hospitalization due to the veteran's service-connected metatarsalgia of the left foot, so as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. The criteria for a schedular disability rating in excess of 10 percent for the service-connected metatarsalgia of the left foot have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5279 (2007). 2. Application of extraschedular provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran seeks an increased disability rating for his service-connected metatarsalgia of the left foot, which is currently evaluated as 10 percent disabling. The second issue on appeal, entitlement to an increased rating for the service-connected median mononeuropathy with osteoarthritis from fracture of the left wrist, is being remanded. In the interest of clarity, the Board will first discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. The Veterans Claims Assistance Act of 2000 (VCAA) The Board has given consideration to the VCAA, which includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate claims for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). The Board has carefully considered the provisions of the VCAA and the implementing regulations in light of the record on appeal, and for reasons expressed immediately below finds that the development of the issue has proceeded in accordance with the provisions of the law and regulations. Standard of review In general, after the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2007). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (the Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Notice The VCAA requires VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claims. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103 (West 2002); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002) [a letter from VA to an appellant describing evidence potentially helpful to the appellant but not mentioning who is responsible for obtaining such evidence did not meet the standard erected by the VCAA]. After having carefully reviewed the record, the Board has concluded that the notice requirements of the VCAA have been satisfied with respect to the issues on appeal. The Board observes that the veteran was informed of the relevant law and regulations pertaining to his increased rating claim in a letters from the RO dated in May 2004 and July 2005 which informed him that "the evidence must show that your service- connected condition has gotten worse." Crucially, the veteran was informed of VA's duty to assist him in the development of his claim and advised of the provisions relating to the VCAA in the above-referenced letters. Specifically, the veteran was advised in the May 2004 and July 2005 letters that VA is responsible for obtaining records from any Federal agency, to include military records, outpatient records from VA treatment facilities and records from the Social Security Administration. The May 2004 and July 2005 letters further indicated that VA examinations were being scheduled to adjudicate his claims [such were accomplished in June 2004 and July 2005]. With respect to private treatment records, the letters informed the veteran that VA would make reasonable efforts to obtain relevant private records. Copies of VA Form 21- 4142, Authorization and Consent to Release Information, were included with the letters, and the veteran was asked to complete this release for each private healthcare provider so that VA could obtain these records on his behalf. The May 2004 and July 2005 letters further emphasized: "If the evidence is not in your possession, you must give us enough information about the evidence so that we can request it from the person or agency that has it. If the holder of the evidence declines to give it to us, asks for a fee to provide it, or VA otherwise cannot get the evidence, we will notify you. It is your responsibility to make sure that we receive all requested records that are not in the possession of a Federal department or agency" [Emphasis as in original]. The May 2004 and July 2005 letters also specifically requested of the veteran: "If you have any evidence in your possession that pertains to your claim[s], please send it to us." This request complies with the "give us everything you've got" requirement contained in 38 C.F.R. § 3.159 (b) in that the RO informed the veteran that he could submit or identify evidence other than what was specifically requested by the RO. The veteran was provided complete notice of the VCAA in the May 2004 letter prior to the initial adjudication of his claims, which was by rating decision dated in September 2004. Thus the requirement of the Court's decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), which appears to stand for the proposition that VCAA notice must be sent prior to adjudication of an issue by the RO, was satisfied. Finally, there have been two significant Court decisions concerning the VCAA. In the first, Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court observed that a claim of entitlement to service connection consists of five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. Because a claim is comprised of five elements, the notice requirements of section 5103(a) apply generally to all five elements of that claim. Therefore, upon receipt of an application for a service connection claim, section 5103(a) and section 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The veteran was provided specific notice of the Dingess decision in a March 2006 letter from the RO, which detailed the evidence considered in determining a disability rating, including "nature and symptoms of the condition; severity and duration of the symptoms; and impact of the condition and symptoms on employment." The veteran was also advised in the letter as to examples of evidence that would be pertinent to a disability rating, such as on-going treatment records, recent Social Security determinations and statements from employers as to job performance and time lost due to service- connected disabilities. With respect to effective date, the March 2006 letter instructed the veteran that two factors were relevant in determining effective dates of increased rating claims: when the claim was received; and when the evidence "shows a level of disability that supports a certain rating under the rating schedule or other applicable standards." The veteran was also advised in the letter as to examples of evidence that would be pertinent to an effective date determination, such as information about continuous treatment or when treatment began, service medical records the veteran may not have submitted and reports of treatment while attending training in the Guard or Reserve. Accordingly, the veteran has received proper notice as to disability rating and effective date pursuant to the Court's Dingess determination. The Board has also considered the Court's recent decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) which held that for an increased-compensation claim, section § 5103(a) requires, at a minimum, that VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. The notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation - e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. The Board finds that the March 2004, July 2005, and March 2006 letters to the veteran specifically advised him that an increased disability rating would require a showing that the veteran's condition had worsened. In addition, the letters invited evidence that would demonstrate limitations in the veteran's daily life and work, such as "a statement from your doctor, containing the physical and clinical findings, the results of laboratory tests or x-rays, and the dates of examinations and tests. You may also submit statements from other individuals who are able to describe from their knowledge and personal observations in what manner your disability has become worse." The Board notes that the VCAA letters of record did not contain notice of the specific schedular criteria or notify the veteran as to the use of diagnostic codes. The veteran was notified of applicable schedular criteria in the November 2005 SOC. It is also apparent from the record that the veteran had actual notice of the applicable criteria. Indeed, the veteran's representative specifically argued the physical conditions warranting an increased rating, and discussed applicable schedular criteria in his April 2006 VA Form 646 statement on behalf of the veteran, and his February 2007 informal hearing presentation. It is therefore clear that the veteran and his representative were aware of the applicable schedular standards. Accordingly, due to the content of the notice given and the veteran's actual knowledge, the Board finds that the veteran has received appropriate VCAA notice for his increased rating claims as contemplated by the Court in Vazquez-Flores. The Board further notes that the veteran's representative has not alleged that the veteran has received inadequate VCAA notice. The veteran is obviously aware of what is required of him and of VA. Because there is no indication that there exists any evidence which could be obtained which would have an effect on the outcome of this case, no further VCAA notice is necessary. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) [VCAA notice not required where there is no reasonable possibility that additional development will aid the veteran]. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate claims for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. The law provides that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claims. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2007). The Board finds that reasonable efforts have been made to assist the veteran in obtaining evidence necessary to substantiate the present claim being decided herein, that of entitlement to an increased rating for metatarsalgia of the left foot, and that there is no reasonable possibility that further assistance would aid in substantiating the claim. In particular, the RO has obtained reports of VA and private medical treatment of the veteran. He was also afforded a VA examinations in July 2005. The report of this examination reflects that the examiner reviewed the veteran's past medical history, recorded his current complaints, conducted appropriate physical examination and rendered appropriate diagnoses and opinions. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2007). The veteran has been accorded the opportunity to present evidence and argument in support of his claim. He has been ably represented by his service organization, which provided argument on his behalf as recently as February 2007. As noted in the Introduction above, the veteran withdrew his request for a personal hearing. Accordingly, the Board will proceed to a decision on the merits as to the issue on appeal. 1. Entitlement to an increased rating for service-connected metatarsalgia of the left foot, currently evaluated as 10 percent disabling. Relevant law and regulations Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2007). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Diagnostic Code 5279 [metatarsalgia, anterior (Morton's disease)] calls for the assignment of a 10 percent disability rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5279 (2007). The provisions of 38 C.F.R. § 4.31 indicate that in every instance where the minimum schedular evaluation requires residuals and the schedule does not provide for a zero percent evaluation, a zero percent evaluation will be assigned when the required symptomatology is not shown. See 38 C.F.R. § 4.31 (2007). Analysis Assignment of diagnostic code The veteran has been service-connected for metatarsalgia of the left foot since a 1993 decision by the Board. His metatarsalgia was initially evaluated by the RO in 1993 pursuant to Diagnostic Code 5021 [myositis], with a noncompensable rating assigned. In its October 2005 decision, the RO granted an increase to 10 percent pursuant to Diagnostic Code 5279 [metatarsalgia]. In connection with his current claim of increase, recent diagnoses of metatarsalgia of the left foot were made in a VA Rehabilitation Center report dated in November 2004 and a VA examination in July 2005. After review of the entire record, the Board finds that the most appropriate diagnostic code is Diagnostic Code 5279, because it specifically addresses the veteran's diagnosed and service-connected left foot disability, metatarsalgia. Schedular rating The veteran is currently assigned a 10 percent disability rating under Diagnostic Code 5279, which is the highest schedular rating available. DeLuca consideration The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2006) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2006). See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). Where, as here, a claimant is already receiving the maximum disability rating available, it is not necessary to consider whether 38 C.F.R. § 4.40 and 4.45 are applicable. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Additionally, with respect to the rating under Diagnostic Code 5279, the Court has held that where a diagnostic code is not predicated on a limited range of motion alone, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Such is the case with Diagnostic Code 5279. Accordingly, the aforementioned provisions of 38 C.F.R. § 4.40 and § 4.45 are not for consideration in this case. Esteban consideration Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2007); see also Esteban v. Brown, 6 Vet. App. 259, 261(1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14 (2007); see also Fanning v. Brown, 4 Vet. App. 225 (1993). As was alluded to in the Introduction, the veteran has been diagnosed as having a number of other foot disorders. Specifically, in November 2004 the examiner also diagnosed the veteran with mild caves deformity and hammertoe deformity of the left foot. The examiner in July 2005 additionally noted claw toe deformity of the left fifth toe and mild osteoporosis of the left foot. The veteran's accredited representative has suggested that such disabilities are somehow part and parcel of the service-connected disability and thus they "should also be rated separately under DC 5277, 5278, 5279, 5280, 5281, 5282, 5293 and 5284." The Board disagrees. The veteran and his representative have presented no competent medical evidence which suggests that the veteran's service-connected left foot disability encompasses anything other than metatarsalgia. See 38 U.S.C.A. § 5107(a) [it is a claimant's responsibility to support a claim with evidence]; see also 38 C.F.R. § 3.159 (a)(1) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. In short, the Board finds that 38 C.F.R. § 4.25 is inapplicable in this case. The medical evidence of record simply does not indicate that the veteran's service-connected metatarsalgia includes any other diagnosed foot disability. As was noted in the Introduction, the representative in effect appears to be raising a claim of entitlement to secondary service connection under 38 C.F.R. § 3.310. That has been referred to the RO for such additional action as may be appropriate. The Board intimates no conclusion, legal or factual, as any such claim raised by or on behalf of the veteran. Hart consideration In Fenderson v. West, 12 Vet. App. 119 (1999), the Court discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court was presented with the question of whether it is appropriate to apply staged ratings when assigning an increased rating. In answering this question in the affirmative, the Court held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. In reaching its conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that time frame. See 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400(o) (2007). Accordingly, the relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. The veteran's claim of entitlement to an increased rating for his left foot disability was received by the RO on April 27, 2004. In its October 2005 decision, the RO granted an effective date for the veteran's service-connected metatarsalgia of the left foot effective as of that date. The question then becomes whether an increase in disability due to the service-connected metatarsalgia was factually ascertainably during the one year period prior to April 27, 2004. The only medical evidence of record during this one year period are reports of evaluations of the veteran on March 15 and 18, 2004. [Indeed, no other relevant medical evidence appears of record for over a decade prior to April 1993.] These reports are inconclusive. Metatarsalgia was not specifically identified, and the veteran's problem was vaguely referred to as "chronic foot pain". Under these circumstances, the Board finds that it was not factually ascertainable that an increase in the service-connected left foot disability due to metatarsalgia occurred prior to April 27, 2004. Extraschedular consideration The Board has considered the question of whether an extraschedular rating may be appropriate for the veteran's metatarsalgia of the left foot. See Bagwell v. Brown, 9 Vet. App. 157 (1966). Under Floyd v. Brown, 9 Vet. App. 88, 95 (1996), the Board cannot make a determination as to an extraschedular evaluation in the first instance. See also VAOPGCPREC 6-96. However, the Board can address the matter of referral of a disability to appropriate VA officials for such consideration. Ordinarily, the VA Schedule for Rating Disabilities will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2007). The Board has not identified an exceptional or unusual disability picture with respect to the veteran's service- connected metatarsalgia of the left foot, and neither has the veteran or his representative. The record does not show that the veteran has required any hospitalization for this disability. There does not appear to have been any significant time lost from work due to this disability. There is no evidence that the veteran is occupationally impaired beyond the level contemplated in the assigned disability ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is a recognition that industrial capabilities are impaired]. In addition, the medical evidence does not document any unusual clinical presentation or any other reason why the veteran's disability may be considered to be exceptional or unusual. For these reasons, the Board has determined that referral of the veteran's service-connected metatarsalgia of the left foot for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. Conclusion For reasons and bases expressed above, the Board finds that the veteran is properly assigned a 10 percent rating for metatarsalgia of the left foot, which is the maximum disability rating under Diagnostic Code 5279. The preponderance of the evidence is against the claim, and the benefit sought on appeal is denied. ORDER Entitlement to an increased disability rating for service- connected metatarsalgia of the left foot is denied. REMAND 2. Entitlement to an increased rating for service-connected median mononeuropathy with osteoarthritis from fracture of the left wrist, currently evaluated as 20 percent disabling. In an October 1991 RO rating decision, the veteran was initially service-connected for fracture of the left wrist with moderately severe limitation of motion, with a 10 percent evaluation assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5215 [limitation of motion of the wrist]. In its September 2004 decision, the RO granted an increase to 20 percent disabling pursuant to Diagnostic Code 5215 and 38 C.F.R. § 4.124a, Diagnostic Code 8515 [incomplete moderate paralysis of the median nerve]. The disability was described as median mononeuropathy with osteoarthritis from fracture of the left wrist. In May 2005, the veteran underwent fusion surgery in his left wrist. In an October 2005 RO rating decision, the disability was still described as median mononeuropathy with osteoarthritis from fracture of the left wrist; it was evaluated pursuant to Diagnostic Code 5214 [favorable ankylosis of the minor wrist], with a 20 percent rating assigned. The veteran was provided a VA examination of his left wrist during July 2005, after his May 2005 fusion surgery on the wrist. It was noted that the veteran's symptoms included weakness, stiffness, and complete loss of mobility in the left wrist. The veteran's wrist had been in a cast, and at the time of the examination the veteran was wearing a soft brace to aid healing, stability, and maintain alignment. The examiner made no observations relating to any continuing neuropathy in the left wrist, probably because the veteran was still recuperating from his surgery. Thus, it appears that the veteran's service-connected disability originally encompassed both orthopedic and neurological components. It is unclear whether the May 2005 wrist fusion surgery eliminated the neurological symptoms. Now that the veteran has had sufficient time to recover from his surgery, a remand for another examination of his left wrist is needed to determine the current severity of his left wrist disability, including a determination as to whether there is any continuing neuropathy in the left wrist. As was discussed above, under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2007). In addition to the orthopedic and (possibly) neurologic disabilities which may be associated with the veteran's service-connected wrist disability, according to the VA examination in July 2005, the veteran had two surgical scars on his left wrist, one of which was noted to be still tender to deep palpation. The examiner should also describe the current condition of the scars for further consideration by the RO. Accordingly, the case is REMANDED to the Veterans Benefits Administration (VBA) for the following action. 1. VBA should schedule the veteran for a physical examination in order to determine the current severity of his left wrist disability, including a determination of whether he has continuing neuropathy in the wrist and its severity, and a description of the current status of the surgical scars on the veteran's left wrist. The claims file must be provided for the examiner to review. Any appropriate diagnostic testing should be conducted. If the veteran is found to have neuropathy in his left wrist that equates to paralysis of the musculospiral nerve (the radial nerve), an opinion should be provided as to whether the paralysis is complete or incomplete. If incomplete paralysis, an opinion should be provided as to whether it is mild, moderate, or severe incomplete paralysis. If there is found to be ankylosis of the left wrist, an opinion should be provided as to whether it is favorable in 20 to 30 degree dorsiflexion; in any other position except favorable; unfavorable in any degree of palmar flexion, or with ulnar or radial deviation; or extremely unfavorable. A report should be prepared and associated with the veteran's claims folder. 2. After undertaking any additional development deemed to be appropriate, VBA should readjudicate the veteran's claim of entitlement to an increased rating for residuals of a left wrist fracture. VBA should give consideration to whether separate evaluations are warranted for any neurological deficits and/or surgical scars on the left wrist. If the benefit sought on appeal remains denied, the veteran and his representative should be provided a supplemental statement of the case and given an appropriate opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if otherwise in order. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ____________________________________________ Barry F. Bohan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs