Citation Nr: 1304055 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 07-06 394A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial compensable disability evaluation for right carpal tunnel syndrome (CTS) from July 1, 2005 to September 13, 2006. 2. Entitlement to an initial compensable disability evaluation for carpal tunnel syndrome (CTS), status post right carpal tunnel release with residual pain and mild weakness, from November 1, 2006. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R.N. Poulson, Counsel INTRODUCTION The Veteran served on active duty from March 1982 to June 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which granted service connection for right CTS, status post right carpal tunnel release with residual pain and mild weakness. The RO assigned a noncompensable evaluation from July 1, 2005 to September 13, 2006; a temporary total evaluation from September 14, 2006 to October 31, 2006 for the Veteran's right wrist carpal tunnel release surgery; and a noncompensable evaluation from November 1, 2006. The issue has been recharacterized to reflect this procedural history and medical evidence. In March 2010, the Board, in pertinent part, denied an initial compensable disability rating for right CTS, status post right carpal tunnel release with residual pain and mild weakness, from July 1, 2005 to September 13, 2006, and from November 1, 2006. The Veteran appealed the Board decision. In March 2012, the United States Court of Appeals for Veterans Claims (Court) issued a judicial order vacating this part of the Board's decision and remanding the matter for further development. FINDINGS OF FACT 1. From July 1, 2005 to September 13, 2006, the Veteran's service-connected right CTS was manifested by mild weakness and subjective complaints of pain, numbness, and tingling; it was not productive of mild, incomplete paralysis of the median nerve. 2. From November 1, 2006, the Veteran's service-connected right CTS, status post carpal tunnel release, has been manifested by no more than mild incomplete paralysis of the median nerve, to include pain on motion, dorsiflexion to 60 degrees, and diminished strength. CONCLUSIONS OF LAW 1. From July 1, 2005 to September 13, 2006, the criteria for an initial compensable evaluation for service-connected right CTS have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1 - 4.7, 4.124a, Diagnostic Code (DC) 8515 (2012). 2. From November 1, 2006, the criteria for an initial 10 percent evaluation for service-connected CTS, status post right carpal tunnel release with residual pain and mild weakness, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1 - 4.7, 4.124a, DC 8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). For initial rating claims, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim of service connection has been more than substantiated and proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Moreover, the Board finds that VA has complied with its duty to assist the Veteran in the development of his claim. The claims file contains records of post-service treatment the Veteran has received from VA, federal, and private treatment providers. He has indicated that he does not receive disability benefits from the Social Security Administration. See 38 C.F.R. § 3.159 (c)(2). In connection with his claim, the Veteran underwent VA examination in August 2007 and August 2008; reports of those examinations are of record. In that connection, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate, as they are predicated on consideration of all of the pertinent evidence of record, to include the statements of the Veteran, and document that the examiner conducted thorough examination of the Veteran and consideration of the evidence. An explanation of the opinions offered by the examiner was provided. In addition, the Veteran has further been given the opportunity to submit evidence, and he has provided written argument in support of his claim. The Veteran has not identified, and the record does not indicate, existing records pertinent to the claim decided herein that need to be obtained. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.97. The Court has indicated that a distinction must be made between a veteran's dissatisfaction with original ratings and dissatisfaction with determinations on later filed claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Thus, the Board will evaluate the issues as claims for higher evaluations of the original awards. When an original rating is appealed, consideration must be given as to whether an increase or decrease is warranted at any time since the award of service connection, a practice known as "staged" ratings. Id. In September 2007, the RO granted service connection for right CTS and assigned a noncompensable evaluation from July 1, 2005 to September 13, 2006, and from November 1, 2006, under 38 C.F.R. § 4.124a, DC 8599-8515. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The Veteran in this case is right-handed. See, e.g., August 2007 VA examination report. The Veteran's neurological disability is rated under 38 C.F.R. § 4.124a, DC 8515 (paralysis of the median nerve). Under DC 8515, a 10 percent disability evaluation is assigned for mild, incomplete paralysis of the median nerve of the major hand. A 30 percent disability evaluation is warranted for moderate, incomplete paralysis of the major hand. A 50 percent disability evaluation is warranted for severe, incomplete paralysis of the major hand. Complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand), pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended, cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm, flexion of wrist weakened, and pain with atrophic disturbances warrants a maximum 70 percent rating. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the 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. When the involvement is bilateral, the ratings should be combined with application of the bilateral factor. Id. The normal range of motion of the wrist is 0 to 70 degrees of dorsiflexion, 0 to 80 degrees of palmar flexion, 0 to 45 degrees of ulnar deviation, and 0 to 20 degrees of radial deviation. 38 C.F.R. § 4.71, Plate I. DC 5215 provides evaluations for limitation of motion of the wrist, and provides a maximum evaluation of 10 percent where dorsiflexion is less than 15 degrees or when palmar flexion is limited in line with the forearm. 38 C.F.R. § 4.71a, DC 5215. The Board will also consider whether this case presents other evidence that would support a higher rating on the basis of functional limitation due to weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of a claimant. 38 C.F.R. § 4.40; accord Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Additionally, "[w]eakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled." 38 C.F.R. § 4.40. The Veteran contends that a 20 percent rating is warranted for his right wrist disability. A December 2005 Functional Capacities Evaluation (FCE) conducted for an unrelated medical problem revealed that strength and range of motion testing of the Veteran's right upper extremity was within normal limits. A March 2006 treatment record from Keesler Air Force Base (AFB) shows that the Veteran complained of right hand pain and weakness of two months' duration. Upon physical examination, there was some diffuse hand/finger tenderness with palpation. There was full range of motion. Tinel's test was negative. Phalen's test was also negative. Grip strength was normal. A sensory examination was intact. Strength testing was normal. In April 2006, the Veteran reported that the right hand pain radiated to the fingers. He described the pain as constant, sharp, and shooting. His fingers "went numb" at night. He had difficulty gripping objects. He reported increased pain while doing landscaping, especially while applying pressure to a trigger of a machine. Physical examination included a positive Phalen's test and a negative Tinel's test. A May 2006 treatment record from Dr. K.R.N. shows that the Veteran's symptoms initially occurred at night, but that he had started having pain during the day. He woke up with numbness and a throbbing feeling in his right hand. Naprosyn helped somewhat. Strength testing was 5/5 except for mild intrinsic hand muscle weakness. Sensory examination was intact to light touch and pinprick, joint, position, and vibration sense. Tinel's sign was negative. Phalen's sign was positive. The assessment was probable entrapment syndrome/CTS. The physician advised the Veteran to start using a wrist brace regularly while sleeping and during the daytime as needed. She recommended evaluation for decompression if there was no significant improvement. A May 2006 Nerve Conduction Study (NCS) revealed prolonged right medial distal motor latency. Right medial sensory latency was in the upper normal range. Amplitude and conduction velocity were normal. Bilateral medial palmar latencies were relatively prolonged compared to ulnar palmar latencies, right side more than left side. Bilateral medial and ulnar F-latencies were normal. Needle EMG was not performed as requested by the Veteran. The impression was moderate entrapment of the right medial nerve at the wrist, CTS. Clinical correlation was advised. A July 2006 treatment record from Dr. A.B. shows that the Veteran complained of pain, numbness and tingling. Range of motion of the right fingers, hand, and wrist was full without pain or instability. Gross motor strength was normal with good grip strength. The median nerve compression test was positive. In September 2006, the Veteran underwent right carpal tunnel release surgery. An April 2007 treatment record from Keesler AFB shows that there was full range of motion of the right wrist. There was no evidence of thenar atrophy or intrinsic wasting. No motor or sensory abnormalities were noted with the exception of subjective numbness to the index and middle fingers. Two point discrimination was less than 6 mm to the index and middle fingers and less than 5 mm for the remaining digits. Testing for carpal tunnel syndrome direct compression, Tinel's, and Phalen's produced numbness and tingling to the thumb, index, and middle fingers. Testing for cubital tunnel syndrome direct compression, Tinel's, and elbow hyperflexion were negative. April 2007 X-rays of the right hand revealed no significant degenerative disease. A May 2007 NCS revealed normal motor and sensory testing with reduced right median amplitude motor nerve, and normal median and ulnar latencies. In June 2007, the Veteran complained of pain in the right hand, thumb, index finger, and middle finger. He also complained of weak grip strength. He denied any numbness and tingling. Upon physical examination, no motor or sensory abnormalities were noted. Two point discrimination was less than 5 mm on all digits. Motor strength testing grip strength was 85 on the right and 77 on the left. Key-pinch was 14 on the right and 15 on the left. There was a well-healed incision at the thenar crease. There was tenderness to palpation at the thumb, index, and middle fingers. The clinician noted that compared to the 2006 pre-operative study, the May 2007 NCS showed that right median motor latency had improved and that amplitude was reduced. The impression was bilateral CTS, right status post carpal tunnel release with some improvement of numbness and tingling, however still with persistent pain and some weakness. The clinician told the Veteran that he could expect improvement of his symptoms up to 12 months status post carpal tunnel release. He also noted the possibility of underlying basilar or phalangeal osteoarthritis early with good grip strength now and function range of motion. The clinician recommended continued observation for three months, at which time he would consider possible carpal tunnel injection versus MRI to rule out scarring of the median nerve. The Veteran submitted to an August 2007 VA neurological examination. His complaints of tingling and numbness of the right index and middle fingers had basically resolved since the September 2006 carpal tunnel release surgery. However, he still complained of constant pain to the digits of the right hand and some weakness. Any type of overuse caused the pain to worsen. The Veteran denied any overt problems with holding or gripping, but stated that he could not grip as strongly as he used to. He was unable to do certain activities anymore, such as golf. He denied any flare-ups of hand or wrist pain, stating that his symptoms were "pretty persistent." He denied any paresthesias, dysesthesias, or any other sensory abnormalities. He also denied fatigue or functional loss, unless he overused his right hand. The examiner noted that the Veteran had difficulty describing what overuse was for him. Upon physical examination, there was no heat, swelling, or erythema noted. Repetitive range of motion testing revealed dorsiflexion to 60 degrees, palmar flexion to 60 degrees, ulnar deviation to 30 degrees, and radial deviation to 20 degrees. Phalen's test was positive. Thelan's test was negative. Distal neurovascular status appeared to be grossly intact. There was pain to palpation of the thumb and index finger. The Veteran was able to make a fist and oppose his right thumb to all of his right digits, although he had some problems accomplishing this to the fourth and fifth digits. He had overall normal grip strength in comparison to his left hand. There was also a well-healed scar over the Thenar crease. The examiner did not have the claims file to review. He did, however, review the results of the May 2006 NCS. The diagnosis was right CTS status post right carpal tunnel release with residual pain and mild weakness to the right hand. The examiner noted that additional limitation of function due to flare-ups or repetitive use could not be determined without resorting to mere speculation. An August 2007 MRI of the right wrist revealed volar bowing of the right flexor retinaculum and increased size and signal of the medial nerve within the carpal tunnel consistent with CTS, and an 8 mm ganglion cyst on the volar aspect of the distal right radius. A September 2007 record from Keesler AFB shows that the Veteran continued to experience pain in his index and middle fingers. The clinician noted that the August 2007 MRI was not done with gadolinium so that the scar tissue was not visualized. The clinician wrote "it is really not clear whether scar tissue is enveloping median nerve or release was incomplete." The Veteran received a peripheral nerve block to the right median wrist. The clinician noted that if the injection provided significant relief, then revision CTS would be recommended. Otherwise, he recommended an MRI with gadolinium or a cervical spine MRI "to try to find out source of [the Veteran's] problems." The clinician prescribed Naprosyn for mild osteoarthritis of the bilateral hands. He recommended that the Veteran wear a wrist splint at all times as much as possible, including at night, especially given the fact that he worked as a plumber. In November 2007, the Veteran reported that the nerve block had not worked. The clinician noted that the April 2007 X-rays showed evidence of very mild osteoarthritis with preserved joint space in both index and middle finger DIP joints. He concluded that some of the Veteran's symptoms were coming from the arthritis. A December 2007 MRI of the right wrist with gadolinium showed a small ganglion cyst volar aspect radius with communication to the radiocarpal joint space, as well as mild CTS. A December 2007 NCS was normal. The Veteran refused an EMG. A February 2008 treatment report from Keesler AFB shows that the Veteran continued to complain of pain in the index and middle finger. He denied numbness or tingling. The clinician reviewed the December 2007 studies and noted that there was no evidence of CTS. However, the MRI with gadolinium showed mild CTS. The record contains the following notation: I do not really know what is going on with this patient. He does not have carpal tunnel and his symptoms are not consistent with any type of nerve compression in the upper extremity. The next place to look is in the cervical spine. Therefore, I will order an MRI of his cervical spine and see if that shows anything. He was given an option of going back to see Dr. Blevens, which he did not desire and an option of exploratory right carpal tunnel surgery, which he also did not desire and I do not think it will help him given the fact that his nerve conduction studies were normal. A February 2008 cervical spine MRI was essentially normal with only mild thickening in the posterior longitudinal ligament noted, but no evidence of cord compression, nerve root impingement, or central canal stenosis. A March 2008 treatment record from Keesler AFB shows that the Veteran continued to complain of persistent right hand pain in the index and middle fingers, muscle cramps, tingling, and numbness. Upon physical examination, grip strength was weak at 60 pounds compared to 90 pounds on the left. Key pinch was 16 on the right and 14 on the left. There was no swelling. Flexion was normal. Phalen's test showed numbness/tingling in the median nerve distribution. Tinel's test of the median nerve was positive. A carpal compression test was positive. The clinician discussed possible revision release and fat pad transfer, which the Veteran declined. The Veteran submitted to an August 2008 VA neurological examination with the same physician's assistant who had conducted the August 2007 VA neurological examination. He complained of swelling, decreased grip strength, constant hand pain, and intermittent numbness to his thumb, index, and middle fingers (usually when he was sleeping). He also complained of overall pain, weakness, fatigue, and functional loss. Neither a splint nor Naprosyn provided any relief. Upon physical examination, a well-healed scar on the palmar aspect from the release surgery was noted. The scar measured 4.5 cm by .1 cm. There was no adherence to underlying tissue. The skin texture appeared to be stable. There was no inflammation, edema, or keloid formation. There was no loss of function, loss of motion, or disfigurement. The Veteran denied any local pain or tenderness. With respect to the right wrist, there was no heat, swelling, or erthyma. On repetitive range of motion testing there was palmar flexion to 50 degrees, dorsiflexion to 60 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. Phalen's and Tinel's testing was negative. There was mild pain with all motion of the wrist. No additional limitation of motion was noted. With respect to the right hand, there was no obvious heat, swelling, or erthyema. The Veteran reported problems fully flexing his right index finger and right middle finger. On repetitive range of motion testing of the index finger there was flexion to 70 degrees at the MCP joint, flexion to 100 degrees at the PIP joint, and flexion to 60 degrees at the DIP joint. On repetitive range of motion testing of the middle finger there was flexion to 70 degrees at the MCP joint, flexion to 100 degrees at the PIP joint, and flexion to 70 degrees at the DIP joint. All other digits revealed full flexion. The Veteran was unable to flex the index and middle fingers to the primary and secondary crease. He was able to oppose all fingers to the thumb without difficulty. Grip strength was equal in both hands. He was unable to make a tight fist with 1 cm gap space regarding the index and middle fingers. The assessment included status post right carpal tunnel release with MRI evidence of recurrence of right CTS. The examiner noted that additional limitation of function due to repetitive use and flare-ups could not be determined without resorting to mere speculation. A July 2010 VA joints examination conducted in connection with the Veteran's claim for service connection for left CTS contains relevant information. At that time, he was working as a superintendant in the Public Works Department. He reported that the CTS reduced his productivity and efficiency at work. There were no impediments to activities of daily living. Upon physical examination of the bilateral hands, there was no redness, warmth, edema, or deformity. Fingers and thumbs were nontender. The Board does not find that the clinical evidence supports a compensable rating for service-connected right CTS for the period from July 1, 2005 to September 13, 2006. Specifically, the Board finds that the clinical evidence does not suggest that the Veteran had mild, incomplete paralysis of the median nerve. Treatment records note his reports of pain, numbness, weakness, and tingling. The Board observes that mild muscle weakness was noted in May 2006. However, physical examinations conducted during this time period reveal no limitation of motion, fatigue, or lack of endurance. The Veteran's grip strength was normal. He had full range of motion in the wrist. There was no reduction in sensory perception. The Veteran's representative contends that a compensable evaluation is warranted during this time period because Dr. K.R.N. described the Veteran's right CTS as moderate. The use of terminology by VA examiners and other medical professionals, although probative evidence, is not necessarily dispositive of an issue as all evidence of record must be evaluated in arriving at a decision regarding an increased rating. See 38 C.F.R. §§ 4.2, 4.6. Indeed, Dr. K.R.N. indicated that clinical correlation was advised. The findings described above correspond to an overall disability level during this time period consistent with a noncompensable rating under DC 8515. However, the Veteran's statements and the clinical evidence from November 1, 2006 demonstrate that his right wrist disability was manifested by constant pain, reduced grip strength, pain throughout the range of motion, and an inability to make a "tight" fist. Based on this disability picture, the Board finds that the Veterans right wrist disability more nearly approximates mild incomplete paralysis of the median nerve during this time period. See 38 C.F.R. § 4.7. Given that the Veteran's sensation and motor function were normal on objective examination at both VA examinations, the Board finds that a 30 percent rating during this time period is not warranted as his disability picture does not more nearly approximate moderate paralysis of the median nerve. Importantly, joint function was not additionally limited after repetitive use at either VA examination. Nor was there loss of reflexes or muscle atrophy. The Board also finds it significant that at the most recent VA examination, the examiner found that the Veteran exhibited no functional limitations. In sum, the Veteran's symptoms are adequately contemplated by the currently assigned 10 percent disability rating. The Veteran contends that he is entitled to a higher rating for his right wrist disability because he cannot completely close his left hand. DC 5229 addresses limitation of motion of individual digits. To warrant a compensable rating for limitation of motion, there must be a one-inch gap between the fingertip and the proximal transverse crease of the palm (with the finger flexed to the extent possible), or extension must be limited by more than 30 degrees. 38 C.F.R. § 4.71a, DC 5229. Such is not shown in this case. With regard to establishing loss of function due to pain, it is necessary that complaints be supported by adequate pathology and be evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Treatment records prior to the September 2006 release surgery reflect no objective evidence of pain on motion. The August 2007 VA examination report notes that the Veteran denied flare-ups of pain, fatigue, and functional loss unless he overused his hand. The Veteran was unable to describe what he meant by "overuse." Thus, the examiner refused to speculate with respect to additional limitation of function. The August 2008 VA examination report noted that on repetitive testing there was mild pain with all motion of the wrist. The effects of pain due to the service-connected right CTS status post carpal tunnel release are contemplated in the currently assigned 10 percent evaluation. There is no indication that pain, due to disability of the right wrist, causes functional loss greater than that contemplated by the evaluations assigned. See 38 C.F.R. § 4.40. The Board has considered whether a higher rating could be provided under DC 5003. The Veteran has been diagnosed with osteoarthritis of the right hand. However, there is no indication, nor has the Veteran or his representative claimed, that such diagnosis is related to his service-connected right CTS. In addition, the record indicates that the Veteran injured his right hand in 1993 after being involved in a motorcycle accident. Furthermore, notwithstanding the November 2007 clinician's characterization of the April 2007 X-ray report, arthritis has not been shown by X-ray studies. The Board has also considered whether a higher rating could be provided under DC 8516 for disabilities affecting the ulnar nerve resulting in the "griffin claw" deformity, due to flexor contraction of the ring and little fingers, very marked atrophy in the dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers, inability to spread the fingers (or reverse), inability to adduct the thumb; and weakened flexion of the wrist, and finds that the Veteran's symptomatology does not meet the criteria under this diagnostic code. 38 C.F.R. § 4.124a, DC 8516. In addition, the Board finds that the Veteran is not entitled to a separate 10 percent rating under DC 5215 because range of motion testing during August 2007 and August 2008 VA examinations did not reveal dorsiflexion limited to less than 15 degrees or palmar flexion limited in line with the forearm. To the contrary, the Veteran's ability to dorsiflex his wrist was limited at most to 60 degrees and palmar flexion was limited at most to 50 degrees. Accordingly, he is not entitled to a separate rating under DC 5215. See 38 C.F.R. § 4.71a, DC 5215. Because the August 2008 VA examination noted the presence of a scar on the Veteran's right wrist, consideration has been given to whether a separate compensable evaluation is warranted for this right wrist scar. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the VA examination report noted the scar measured 3.5 cm by .1 cm, was not painful on examination, and was not manifested by inflammation, edema, adherence to underlying tissue, or keloid formation. The scar did not have any other disabling effects. Thus, the evidence does not support a separate rating for a right wrist scar. See 38 C.F.R. § 4.118, DCs 7800 - 7805. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability ratings reflect. The Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Further, in consideration of the Veteran's assertions, an initial 10 percent rating has been assigned from November 1, 2006. In light of the holding in Hart, the Board has considered whether the Veteran is entitled to additional "staged" ratings. Based upon the record, the Board concludes that at no time during the appeal period has this disability been more disabling than as currently rated under the present decision of the Board. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable evaluation from July 1, 2005 to September 13, 2006, and that the criteria for entitlement to an initial 10 percent evaluation, but no higher, from November 1, 2006 have been met. Consideration has also been given regarding whether the schedular evaluations are inadequate, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating, otherwise, the schedular evaluation is adequate, and referral is not required. Id. at 116. The schedular evaluations in this case are adequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected disorder, but the medical evidence reflects that those manifestations are not present in this case. The medical evidence generally shows subjective complaints of constant pain, numbness, weakness, and tingling. DC 8515 specifically addresses this type of impairment. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's right wrist disability. The Veteran has not been hospitalized for treatment, other than the September 2006 release surgery. While the July 2010 VA examination report and the Veteran's complaints indicate that right wrist pain affected his ability to perform his duties at work, he did not report any lost time from work. Therefore, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. Moreover, the Board has considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) is present here. None of the VA examination reports show that the Veteran is unemployable solely due to his right wrist disability. In fact, the evidence of record establishes that he has worked throughout the appeal period and has not lost time from work due to this disability. Therefore, any inferred TDIU claim is inapplicable in this case. ORDER An initial compensable evaluation for right CTS from July 1, 2005 to September 13, 2006, is denied. An initial compensable evaluation of 10 percent, but no higher, for CTS, status post right carpal tunnel release with residual pain and mild weakness, from November 1, 2006 is granted, subject to the law and regulations governing the payment of monetary awards. ____________________________________________ J.A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs