Citation Nr: 1126355 Decision Date: 07/13/11 Archive Date: 07/19/11 DOCKET NO. 05-39 908 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for carpal tunnel syndrome of the left wrist, to include as secondary to the service-connected right wrist disorder. 2. Entitlement to an increased rating for traumatic severance of the right wrist flexor and median and ulnar nerves, with carpal tunnel syndrome, currently evaluated as 40 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from July 1972 to December 1974. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a September 2004 rating decision, by the St. Petersburg, Florida, Regional Office (RO), which denied the claim of entitlement to a rating in excess of 40 percent for traumatic severance of the right wrist flexor and median and ulnar nerves; that rating also denied service connection for carpal tunnel syndrome of the left wrist, to include as secondary to the service-connected right wrist disorder. The Veteran perfected a timely appeal to that decision. Subsequently, in a December 2007, a decision review officer's (DRO) decision granted service connection for right carpal tunnel syndrome, effective February 9, 2004; this disability was included with the service-connected residuals of trauma severance of flexor tendons, right wrist and ulnar nerves. In October 2009, the Board remanded the case to the RO for further evidentiary development. Following the requested development, a supplemental statement of the case (SSOC) was issued in October 2010. The Board notes that, in his November 2005 substantive appeal (VA Form 9), the Veteran requested a hearing before a Veterans Law Judge (VLJ) at the RO (Travel Board Hearing). In April 2008, the RO sent the Veteran notice that a Travel Board hearing was scheduled for May 19, 2008. He failed to appear at the hearing or give any reason for his failure to appear. Pursuant to 38 C.F.R. § 20.702(d) (2010), the Veteran's case was processed as though the request for hearing had been withdrawn. FINDINGS OF FACT 1. Carpal tunnel syndrome of the left wrist was not present in service, and is not currently objectively demonstrated. 2. The Veteran's traumatic severance of the right wrist flexor and median and ulnar nerves, with carpal tunnel syndrome, is not manifested by severe incomplete paralysis of the lower radicular group. CONCLUSIONS OF LAW 1. Carpal tunnel syndrome of the left wrist was not incurred in or aggravated by service, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2010). 2. The criteria for a rating in excess of 40 percent for traumatic severance of the right wrist flexor and median and ulnar nerves, with carpal tunnel syndrome, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8512 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Duty to Notify and Assist. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case (SOC) or supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of a letter dated in April 2004 from the RO to the Veteran which was issued prior to the RO decision in September 2004. Additional letters were issued in February 2005, May 2008, and February 2010. Those letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence and/or information in his possession to the RO. The Board finds that the content of the above-noted letters provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to the claims decided herein has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of this appeal. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claims, and to respond to VA notice. The Board is unaware of any outstanding evidence or information that has not already been requested with respect to the claim for increase for the right wrist disorder. The Veteran has been afforded VA examinations on the issues decided herein. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations afforded the Veteran are adequate. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran, and examined the Veteran. Findings necessary to apply the criteria for carpal tunnel syndrome of the right hand have been made. Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. Therefore, no useful purpose would be served in remanding either of the issues decided herein for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Factual background. The Veteran entered active duty in July 1972; the enlistment examination was negative for any complaints or findings of a left wrist disorder. The STRs indicate that, on October 18, 1973, the Veteran was admitted to the base hospital after slipping and falling and lacerating his right forearm and right wrist on a glass window. The Veteran also had several deep lacerations in the forearm on the ulnar surface. The impression was laceration of all flexor tendons, median and ulnar nerve of the right wrist and ulnar artery, and lacerations to the forearm. Operative exploration revealed a complete transverse severance of the median nerve and ulnar nerve at the wrist and the ulnar artery and all flexor profundus and flexor digitorum longus tendons, also the flexor carpi ulnaris tendon and flexor pollicis longus tendons. They were all repaired. The Veteran underwent irrigation and debridement of the wound; he was placed in a bulky hand dressing reinforced with plaster. A medical board proceeding report, dated July 22, 1974, indicated that the Veteran was found to be medically unfit for further military service due to laceration of the right wrist, involving profundi and sublimis flexor tendons of the digits two through four, and involving median and ulnar nerves, with neuroma formation post resection and anastomosis; no artery involvement was noted. By a rating action in February 1975, service connection was granted for lower radicular group paralysis of, incomplete, severe, right, major, manifested by neuropathy, severe, median nerve, right, manifested by absence of thenar muscle control and anesthesia of thumb, index and long fingers; neuropathy, severe, ulnar nerve, right, manifested by absence of intrinsic muscle function and anesthesia of small and ring fingers; laceration, wrist, right (dominant) involving profundi and sublimis flexor tendons of the digits two through four, and involving median and ulnar nerves, with neuroma formation post resection and anastomosis; limitation of motion, flexor tendons to index, long, ring and small fingers, manifested by 90 degree flexion of pit with wrist in neutral position; and atrophy, mild, muscle thenar, right, secondary to median nerve laceration with marked loss of full apposition. A 50 percent rating was assigned, effective December 21, 1974. Following a VA examination in March 1980, an April 1980 rating decision recharacterized the Veteran's disorder as residuals, trauma, severance of flexor tendons, right wrist and median and ulnar nerves; a 40 percent rating was assigned, effective January 7, 1980. Medical evidence of record, dated from December 1984 to November 1993, including VA as well as private treatment reports show that the Veteran received ongoing clinical evaluation and treatment for his residuals of his right wrist injury. In a statement, dated in November 1993, Dr. B. A. H. noted that the Veteran was referred for a neurological evaluation after he was seen in the office with complaints of right wrist pain and right hand numbness which he stated had been present since July. A neurological examination revealed altered sensation in the right median nerve distribution and there was tenderness to palpation at the right wrist with a positive Tinel's sign. Dr. H. stated that the Veteran's complaints were consistent with a right carpal tunnel syndrome. In a statement in support of claim (VA Form 21-4138), received in February 2004, the Veteran requested an increased rating for his right wrist disorder; he also stated that he now had problems with both arms and hands. The Veteran was afforded a VA examination in July 2004. At that time, the Veteran indicated that he started coming to the VA in 1993; he has been seen for what is believed to be carpal tunnel syndrome on the right wrist. The Veteran indicated that he still goes to the Naval Air Station from time to time because of pain in the wrist area. It was noted that the Veteran works for the postal service, and he has continued to work there for a number of years. It was also noted that, in September 2002, the Veteran suffered a stroke which involved the left side, the left arm and the left leg. The Veteran reported that he has had some residual weakness and numbness in the right upper extremity and numbness in the left heel area from his stroke. He further stated that he has also developed symptoms of a carpal tunnel syndrome in his left wrist and wears a cock-up brace on that wrist as well as on the right wrist. On examination, it was noted that the Veteran came in wearing both splints on his wrists and he was examined without the splints. He had a curved 4-inch scar over the right volar wrist, which was only mildly tender from its previous initial surgery and from his original laceration. He had a 5-inch curved longitudinal scar over the right wrist from the second surgery that was done to remove scar tissue. He also had an oval 3x2 inch scar over the proximal forearm from the original laceration, which was nontender. He had a small scar over the PIP joint of the index finger which was also nontender. Tapping his right wrist, he had some pain going into his fingers, but it was into all fingers and not just the median nerve distribution which would be characteristic of a carpal tunnel syndrome. He had a full range of motion of the right wrist with 80 degrees of extension, 50 degrees of palmar flexion, radial deviation to 35 degrees, and ulnar deviation to 40 degrees of discomfort on ulnar deviation. He lacked 20 degrees of extension at the PIP joints actively of all the fingers, the index to the little finger. His thumb had a full range of motion. He had full flexion of all his fingers and could reach the distal palmar crease with the tips of the index through the fifth finger. He had some weakness to grip on doing the motions; however, compared to the left wrist. He had some dysesthesia, which means some abnormal sensation with pinwheel examination over all of the fingers, form the index to the fifth finger, but had protective sensation. He had good circulation in the right hand area. He had some loss of normal sensation also over the dorsal surface of the right hand area. The examiner stated, in summary, the examination showed evidence of median nerve dysfunction as far as sensation, and some mild loss of strength in the flexion of the right fingers. He had 20 degrees loss of range of motion in full extension of all of the PIP joints of his right hand. The pertinent diagnosis was laceration, severe of the right wrist, proximal forearm, and index finger of the right hand with evidence of injury to the median nerve and to the tendons of the fingers of the right hand. The examiner stated that the Veteran does have some functional impairment of having to wear wrist splints and some weakness in full gripping strength. It was noted that he does work for the postal service, and sometimes he is able to work and do his job despite his mild functional loss. It was determined that the stroke had no bearing on the Veteran's right service-related hand and wrist injury. The examiner further stated that there was some mild narrowing of the wrist joint itself at the radial carpal joint, which he believed can be attributed to the injury and reported a diagnosis of degenerative arthritis, mild to moderate of the right wrist. Subsequently received in 2005 were VA progress notes dated from April 1979 to August 2005. These records show that the Veteran received ongoing clinical evaluation and treatment for bilateral carpal tunnel syndrome, manifested by complaints of numbness, tingling and pain in both hands. The Veteran was referred for an electromyography study in August 2005. The pertinent findings were right carpal tunnel syndrome, moderately severe; there was no evidence of carpal tunnel syndrome on the left; there was no evidence of left or right ulnar compression at the elbow or at Guyon's canal; and there was no evidence of cervical radiculopathy on the left or right. VA progress notes dated from October 2006 through November 2007 show that the Veteran received ongoing clinical evaluation and treatment for bilateral carpal tunnel syndrome, manifested by complaints of numbness, tingling and pain in both hands. The Veteran was afforded a VA examination in November 2007. At that time, the Veteran complained of carpal tunnel syndrome of the right hand; he described primarily the ulnar nerve distribution through the hand, all the small finger, medial half of the ring finger, right hand. No involvement of the radial distribution and slight tingling in the fingertips and very proximal slight tingling sensation at the base of the thumb, plus a portion of the thumb, index finger, intertriginous space, palm of the right hand. The Veteran also described sensations in his left hand that really did not match up with carpal tunnel in any way. The Veteran stated that he was not really sure if he had carpal tunnel in the left hand or not, but he did feel that the left hand was caused by or the result of the initial injury and surgeries to the right hand. The Veteran also stated that he was not sure whether it was the overuse of the left hand that caused this syndrome on the left side as a result of not being able to use his dominant right hand, but he was certain that it must be connected one way or the other. The Veteran also complained of right hand and finger flexor spasm deformity, which is relatively "fixed," although it is not firmly ankylosed, it remained pretty much a "fixed position of carriage." It was noted that the Veteran was now unemployed secondary to his medical problems. On examination, the Veteran was able to flex all four fingertips and touch the palmar crease of both hands, although he did have the flexion-type deformities on the right; he could still fold all the joints voluntarily and touch the fingertips to the palmar crease, right hand as well as the left hand, no gaps remaining. He could then bring the thumb tip in flexion and abduction across and touch the ring finger DIP joint on both sides. Looking at the four fingers on the right hand, the Veteran's MCP joint had a normal 0 to 100 degrees range of motion in the MCP joint of the small, ring, middle and index fingers on the right hand, as well as the left hand. On examining the PIP joints individually, small finger PIP joint in flexion was only maximum 20 degrees; ring finger maximum 22 degrees; middle finger maximum 16 degrees in flexion and index finger maximum of 30 degrees flexion. Finally, normal PIP joint flexion of all four fingers of the left hand. The DIP joints 0 to 6 degrees small finger was the maximum flexion; 0 to 14 degrees in the ring finger maximum DIP flexion; 0 to 6 degrees middle finger right DIP flexion and finally 0 to 21 degrees right index finger maximum flexion. The Veteran generally had normal range of motion in the left hand DIP joints. The right wrist had full range of dorsiflexion and extension movement. The wrist palmar flexion was full in the right wrist and the same was true of dorsiflexion or extension and palmar flexion in the left wrist. He had normal and full radial versus ulnar, lateral and medial flexion in both wrists. The examiner stated that there is only one carpal tunnel syndrome tested and documented here; that is the right carpal tunnel based on nerve conduction study and EMG testing performed in 2006. The examiner further stated that there was never accurate documentation of carpal tunnel on the left side. In fact, the EMG/NCS testing was always negative in the left hand for median nerve involvement. The examiner concluded that you must have carpal tunnel syndrome to have it result from something. The examiner stated that, at this time, there is no diagnosable carpal tunnel syndrome in the left hand; it does not matter what may or may not have caused it or what it is secondary to, because it is not there. The examiner stated that it is at least as likely as not that only the right wrist is secondary to the initial injury in service, which was a laceration of the right median nerve and right ulnar nerve at the carpal tunnel area. He stated that there was no evidence to support the theory of the left ulnar nerve, left median nerve, left upper extremity or left lower extremity having any involvement or connection whatsoever directly or indirectly or by aggravation to the pre-existing right wrist laceration in service or repair of that laceration x2 operations. Received in February 2010 were VA progress notes dated from May 2007 to April 2008. These records show that the Veteran received ongoing clinical evaluation and treatment for carpal tunnel syndrome, right wrist. Received in March 2010 was an administrative decision from the Social Security Administration (SSA), dated in September 2007, wherein it was determined that the Veteran had not engaged in substantial gainful activity since September 24, 2002, due to many disabilities, including right carpal tunnel syndrome and ulnar neuropathy, status post trauma to the right wrist. It was determined that the Veteran had been disabled under the provisions of the Social Security Act beginning in September 2002. Associated with the decision were medical records dated from August 1995 to February 2007. These records show that the Veteran received ongoing clinical attention and treatment for several disabilities, including symptoms of his right carpal tunnel syndrome. III. Legal Analysis-Service Connection. Service connection is warranted for disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"--the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Holton v. Shinseki, 557 F.3d 1362 (2009). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2010). Service connection may also be established for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a); See Harder v. Brown, 5 Vet. App. 183, 187 (1993). Prior to October 10, 2006, the provisions of 38 C.F.R. § 3.310 directed, in pertinent part, that disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. The United States Court of Appeals for Veterans Claims (Court) clarified that service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service-connected disorder has aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). There has been an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen v. Brown, 7 Vet. App. 439 (1995) (which allowed for secondary service connection on an aggravation basis), it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which strongly suggests that the recent change amounts to a substantive change in the regulation. Given what appear to be substantive changes, and because the Veteran's claim was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which version favors the claimant. 38 C.F.R. § 3.310 (2006). A claim of service connection must be accompanied by medical evidence establishing that the claimant currently has the claimed disability. Absent proof of a present disability, there can be no valid claim. See, e.g., Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (38 U.S.C. § 1110 requires current symptomatology at the time the claim is filed in order for a veteran to be entitled to compensation); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997) (38 U.S.C. § 1131 requires the existence of a present disability for VA compensation purposes); Brammer v. Derwinski, 3 Vet. App. 233, 225 (1992) (noting that service connection presupposes a current diagnosis of the claimed disability); Chelte v. Brown, 10 Vet. App. 268 (1997) (observing that a "current disability" means a disability shown by competent medical evidence to exist at the time of the award of service connection). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. In this case, the Veteran contends that he has carpal tunnel syndrome of the left wrist that is the result of his active military service or secondary to a service-connected disability. The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for carpal tunnel syndrome of the left wrist. A review of the service treatment records reveals no complaints or diagnoses consistent with carpal tunnel syndrome of the left wrist. While the post service treatment records show complaints of pain and numbness in the left arm, his symptoms have not been attributed to carpal tunnel syndrome. Significantly, EMG studies conducted in August 2005 found no evidence for carpal tunnel syndrome in the left arm. Moreover, following a VA examination in November 2007, the examiner stated that there is only one carpal tunnel syndrome tested and documented here; that is the right carpal tunnel based on nerve conduction study and EMG testing performed in 2006. The examiner further stated that there was never accurate documentation of carpal tunnel on the left side. In fact, the EMG/NCS testing was always negative in the left hand for median nerve involvement. The examiner stated that, at this time, there is no diagnosable carpal tunnel syndrome in the left hand; it does not matter what may or may not have caused it or what it is secondary to, because it is not there. Thus, an essential requirement for service connection is not met, namely a current diagnosis of the claimed disability. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. Absent evidence of current carpal tunnel syndrome of the left wrist which could be attributed to active service, the Board finds that service connection for carpal tunnel syndrome of the left wrist is not warranted. Carpal tunnel syndrome is not a condition under case law that has been found to be capable of lay observation and the determination as to the presence of carpal tunnel syndrome therefore is medical in nature, that is, not capable of lay observation. Savage v. Gober, 10 Vet. App. 488, 498 (1997) (On the question of whether the veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent); Barr v. Nicholson, 21 Vet. App. 303 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). As the diagnosis of carpal tunnel syndrome is not capable of lay observation and as the question of medical causation, that is, evidence of an association or link between right carpal tunnel syndrome and an established injury or disease in service, where a lay assertion on medical causation is not competent evidence, Grottveit v. Brown, 5 Vet. App. 91, 93 (1993), competent medical evidence is required to substantiate the claim. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. As a lay person, the Veteran is not qualified through education, training, and expertise to offer an opinion on a medical diagnosis, not capable of lay observation, or on medical causation. The Board therefore rejects the Veteran's statements relating right carpal tunnel syndrome to active service. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). IV. Legal Analysis-Higher Evaluation. Disability evaluations are determined by the application of a schedule of ratings which is based upon average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 38 C.F.R. § 4.1 (2010) requires that each disability be viewed in relation to its history, and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 (2010) requires that medical reports be interpreted in light of the entire recorded history, and that each disability must be considered from the point of view of the veteran's working or seeking work. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is to be assigned. The requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a). 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. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), 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. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. The RO has rated the Veteran's right wrist disorder by analogy under 38 C.F.R. § 4.124a Diagnostic Code 8512. See 38 C.F.R. §§ 4.20, 4.27. This section concerns the lower radicular group. As the Veteran is right-handed, the criteria for a major extremity apply. Under 38 C.F.R. § 4.124a, Diagnostic Code 8512, for paralysis of the lower radicular group, a 20 percent rating is assigned when there is mild incomplete paralysis. Moderate incomplete paralysis corresponds to a 40 percent rating for a major extremity. Severe incomplete paralysis corresponds to a 50 percent rating for a major extremity. Where there exists complete paralysis, with paralysis of all intrinsic muscles of the hand, and some or all flexors of the wrist or fingers (and substantial loss of use of the hand), a 70 percent rating is warranted for the major extremity. Also, Diagnostic Codes 8612 and 8712 correspond to neuritis and neuralgia affecting the lower radicular nerve group, respectively. A note in the Rating Schedule pertaining to "Diseases of the Peripheral Nerves" provides that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Codes 8510 through 8540 (2010). Neurologic disabilities are rated on a scale from mild incomplete paralysis to complete paralysis for the nerve or nerve group involved. 38 C.F.R. § 4.124a (2010). The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than that which occurs for a complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123 (2010). Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2010). The Board notes that words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2010). Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. §§ 4.2, 4.6 (2010). Having carefully reviewed the evidence, the Board has concluded that an evaluation in excess of 40 percent is not warranted for this disability. Based upon the evidence of record, the Board finds the Veteran's service-connected traumatic severance of the right wrist flexor and median and ulnar nerves, with carpal tunnel syndrome, is presently manifested by less than complete paralysis of the lower radicular nerve group. It is significant to note that there is no evidence of paralysis to the intrinsic muscles of hand or the flexors of the wrist and fingers and no evidence of complete paralysis to the median or the ulnar nerves. The record discloses that the Veteran suffers from neuralgia and neuritis, but that paralysis is not present. Although weakness has been noted, the Veteran does retain some function of his right hand. Significantly, on the occasion of the recent VA examination in November 2007, the right wrist had full range of dorsiflexion and extension movement. The wrist palmar flexion was full in the right wrist. He had normal and full radial versus ulnar, lateral and medial flexion in both wrists. There is no evidence of ankylosis of the thumb which would warrant a higher evaluation, nor is there evidence of ankylosis of all digits of the right hand. Therefore, the claim for entitlement to a rating in excess of 40 percent must be denied. The Board accepts that the Veteran has functional impairment, pain, and pain on motion. See DeLuca. The Board also finds the Veteran's own reports of symptomatology to be credible. Nevertheless, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher evaluation. In reaching this conclusion, the Board has considered the Veteran's statements pertaining to this disability. However, the more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned evaluation for this disability is appropriate. The evidence preponderates against the claim. Accordingly, an increased evaluation for this disability is denied. 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b) (1). (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step--a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Veteran's right hand disability is manifested by limitation of motion, functional impairment, and pain. These manifestations are contemplated by the rating schedule. The most recent VA examiner did not indicate that the disability caused marked interference with employment. The disability has also not required any recent periods of hospitalization. No other exceptional factors have been reported. As such, the criteria for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b) (1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Service connection for carpal tunnel syndrome of the left wrist is denied. Entitlement to a rating in excess of 40 percent, for traumatic severance of the right wrist flexor and median and ulnar nerves, with carpal tunnel syndrome, is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs