Citation Nr: 1307740 Decision Date: 03/08/13 Archive Date: 03/11/13 DOCKET NO. 09-29 183 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for a left hand disability, claimed as secondary to a left thumb disability. 2. Entitlement to service connection for a left arm disability, claimed as secondary to a left thumb disability. 3. Entitlement to service connection for pain disorder, claimed as secondary to a left thumb disability. 4. Entitlement to an increased disability rating for arthritis of the left wrist, in excess of 10 percent. 5. Entitlement to an increased disability rating for neurological and muscular residuals of a left thumb laceration, in excess of 20 percent. 6. Entitlement to an increased disability rating for scar of the left thumb, in excess of 10 percent. 7. Entitlement to an increased disability rating for headaches, in excess of 0 percent prior to November 18, 2011, in excess of 30 percent since November 18, 2011. 8. Entitlement to an increased initial disability rating for a deviated nasal septum, in excess of 0 percent prior to November 18, 2011, in excess of 10 percent since November 18, 2011. 9. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from May 29, 1989 to September 29, 1989, and from September 1, 1990 to September 30, 1990. This appeal comes before the Board of Veterans' Appeals (Board) from a January 2008 rating decision of the RO in Louisville, Kentucky. The Board notes that the RO did not include the issue of entitlement to an increased initial rating for the service-connected deviated nasal septum on the most recent Supplemental Statement of the Case. The Veteran appealed the initial rating of 0 percent assigned in a July 2009 rating decision, which was effective from January 12, 2007. In a December 2011 rating decision, the RO granted a 10 percent rating for the deviated nasal septum, effective November 8, 2011. The RO informed the Veteran that this was considered a full grant of benefits and therefore the appeal was closed. Inasmuch as higher ratings are available before and after the effective date of the 10 percent rating on schedular and/or extraschedular bases, and the Veteran is presumed to seek the maximum available benefit for a disability, the Board has characterized this issue as reflected on the title page. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993). In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. The issues of entitlement to service connection for a pain disorder, a left hand disability, a left arm disability, and entitlement to TDIU are each addressed in the REMAND below and are each REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the issues decided herein has been accomplished. 2. The Veteran is right handed. 3. For the entire period of this appeal, the Veteran's arthritis of the left wrist has been manifested by X-ray evidence of arthritis with painful motion. 4. For the entire period of this appeal, the Veteran's left thumb laceration muscular and neurological residuals have been manifested by incomplete paralysis, neuritis, or neuralgia of the median nerve that is moderate in degree. 5. For the entire period of this appeal, the Veteran's left thumb scar has been manifested by a single painful scar which measures 4 centimeters, and which is not deep and not unstable. 6. Prior to and since November 18, 2011, the Veteran's deviated nasal septum was manifested by at least 50 percent obstruction on each side. 7. Prior to and since November 18, 2011, the Veteran's headaches have been manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating higher than 10 percent for a left wrist disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2012). 2. The criteria for a disability rating higher than 20 percent for a left thumb neurological and muscle disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8515 (2012). 3. The criteria for a disability rating higher than 10 percent for a scar of the left thumb have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59 (2012), 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). 4. Prior to November 18, 2011, the criteria for an initial disability rating of 10 percent for a deviated nasal septum are met; a disability rating in excess of 10 percent are not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6502 (2012). 5. Since November 18, 2011, the criteria for an initial disability rating higher than 10 percent for a deviated nasal septum have not been met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6502 (2012). 6. Prior to November 18, 2011, the criteria for an initial disability rating of 50 percent for headaches are met; the criteria for an initial rating in excess of 50 percent are not met for any portion of the period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2012). 7. Since November 18, 2011, the criteria for an initial disability rating of 50 percent for headaches are met; the criteria for an initial rating in excess of 50 percent are not met for any portion of the period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability Ratings - Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. When the schedule does not provide a zero percent evaluation for in a Diagnostic Code, a zero percent evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Although the claimant's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In Hart v. Mansfield, 21 Vet. App. 505, 511 (2007), the CAVC extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Analysis of Rating for Left Wrist The current appeal arises from a claim received at the RO on January 12, 2007. In a July 2009 rating decision, the RO granted service connection for arthritis and juxta-articular demineralization of the left wrist and assigned a 10 percent initial rating under Diagnostic Code 5010-5215, effective January 12, 2007. Diagnostic Code 5010 provides for a rating in accordance with degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 provides as follows: Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: 20 percent with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations; 10 percent with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. The 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of wrist motion is rated under Diagnostic Code 5215. A 10 percent rating is assigned where dorsiflexion is less than 15 degrees, or where palmar flexion is limited in line with forearm. The 10 percent rating is the maximum rating available for limitation of wrist motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5215. Diagnostic Code 5214 governs ankylosis of the wrist. Where ankylosis is unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation, a 40 percent rating is for application for the minor appendage. Where ankylosis is in any other position, except favorable, a 30 percent rating is for application for the minor appendage. Where ankylosis is favorable in 20 degrees to 30 degrees dorsiflexion, a 20 percent rating is for application for the minor appendage. Extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. See 38 C.F.R. § 4.71a, Diagnostic Code 5214. In the January 2007 claim, the Veteran asserted that he was suffering from deterioration of the bone in the wrist. In argument dated in August 2009, the Veteran asserted that he had developed an increased aching and pain in the wrist. The Veteran's representative asserted in the informal hearing that the Veteran had functional impairment, to include weakness, limitation of motion, and pain on movement, and that an evaluation in excess of 10 percent was warranted. The report of VA examination in November 2011 reveals that palmar flexion was measured to 60 degrees, with onset of pain at 60 degrees. Dorsiflexion was measure to 60 degrees, with onset of pain at 60 degrees. The Veteran was able to perform repetitive-use testing with 3 repetitions. There was no change in the measured range of motion following repetition. Functional loss was described as less movement than normal, pain on movement, and weakened movement. Strength with dorsiflexion and palmar flexion was 4 out of 5, described as active movement against some resistance. The report of VA examination in July 2010 reveals no deformity, no giving way, no effusion, no dislocation, subluxation, or locking episodes, no incoordination, and no instability. Symptoms included pain, stiffness, and weakness. Dorsiflexion was measured from 0 to 20 degrees; palmar flexion was from 0 to 20 degrees; radial deviation was from 0 to 10 degrees; and ulnar deviation was from 0 to 20 degrees. There was severe impairment regarding sports; moderate impairment regarding recreation and chores, mild impairment regarding exercise and dressing, and no impairment regarding shopping, traveling, feeding, bathing, toileting, grooming, and driving. An October 2009 occupational therapy note reveals the Veteran's report that his pain is getting worse and his hand is becoming increasingly dysfunctional. Range of motion was 32 degrees of wrist flexion, 10 degrees of extension, 3 degrees of radial deviation, and 6 degrees of ulnar deviation. The report of VA examination in February 2009 reveals dorsiflexion measured from 0 to 50 degrees, with pain at 50 degrees, palmar flexion from 0 to 60 degrees, with pain at 55 degrees, radial deviation from 0 to 20 degrees without pain, and ulnar deviation from 0 to 35 degrees, with onset of pain at 30 degrees. Measurements were essentially equivalent and reproducible on 3 repeat tests without functional loss. Sequential alternate hand testing of grip strength found the following in pounds per square inch {age-based normal values in brackets}: Dominant Right = 118; 116; 110, with 114.6 average {120}; Left = 35; 30; 26, with 30.3 average {113}. Sequential alternate hand testing of lateral pinch grip strength found the following in pounds per square inch: Dominant Right = 25; 24; 24, with 24.3 average {26.1} Left = 14; 14; 12, with 13.3 average {25.6}. There was no deformity, giving way, instability, stiffness, weakness, incoordination, decreased speed of joint motion, subluxation or dislocation, locking episodes, effusion, or inflammation. There is essentially no dispute as to the facts with respect to the left wrist disability. The Veteran contends that he has deterioration of the bone of the wrist, and that this limits motion of the wrist, makes motion painful, and results in weakness. The clinical evidence substantiates these assertions showing motion that is limited due to pain and weakness. The maximum schedular rating is already assigned for these symptoms. While higher ratings are available on the basis of ankylosis, there is no assertion that the Veteran has ankylosis, and the measured ranges of motion on clinical examination indicate that he does not have ankylosis. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). The results in this case exclude the possibility that the range of motion was ever limited-either by functional loss due to pain or structural limitation-to approximate union of the bone across the joint. In fact, the clinical evidence reflects that, despite the onset of pain, the Veteran could still move his wrist in each plane of motion, and that the neutral position was obtainable. The issue is not whether pain additionally limits the motion, but whether that additional limitation would be the equivalent of ankylosis. For the reasons stated, the Board finds that the weight of the evidence demonstrates that a disability rating in excess of 10 percent for the left wrist is not warranted. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Analysis of Rating for the Left Thumb Service connection for the left thumb muscular and neurological disability was granted in May 1992 rating decision with a 0 percent rating assigned under Diagnostic Code 5308, effective November 26, 1991. In an August 1993 rating decision, a separate 10 percent rating was assigned for the scar associated with the left thumb disability pursuant to Diagnostic Code 7804, effective November 26, 1991. In an August 1994 rating decision, an increased rating of 10 percent was assigned for the right thumb muscular and neurological disability pursuant to Diagnostic Code 5309, effective November 26, 1991. In a July 1997 rating decision, the RO granted an increased 20 percent rating for the left thumb muscular and neurological disability, pursuant to Diagnostic Code 5309-8515, effective January 10, 1994. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. The current appeal arises from a claim for increase received at the RO on January 12, 2007. The Board will consider scar residuals and neurological/muscular residuals as separate matters below. Under Diagnostic Code 5309 (Muscle Group IX), which is currently assigned, ratings are base on limitation of motion, with a minimum rating of 10 percent. In this case, the RO rated on the basis of neurological impairment rather than limitation of motion. Nevertheless, the provisions governing limitation of motion are as follows. A 20 percent rating is for application with a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; a 10 percent rating is for application with a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; a 0 percent rating is for application with a gap of less than one inch (2.5 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. See 38 C.F.R. § 4.71a, Diagnostic Code 5228. Ankylosis of the thumb warrants a 20 percent rating where the ankylosis is in an unfavorable position; a 10 percent rating is warranted for ankylosis in a favorable position. See 38 C.F.R. § 4.71a, Diagnostic Code 5224. As the Veteran is currently in receipt of the maximum rating available for a limitation of thumb motion, a higher rating under Diagnostic Code 5228 or 5224 is not warranted. Also pertinent, the original diagnostic code assigned by the RO is Diagnostic Code 5308 (Muscle Group VIII). Under that code, a 30 percent rating is available for severe impairment of the dominant hand, a 20 percent rating is available for severe impairment of the minor hand. Moderately severe impairment of either hand warrants a 20 percent rating. Moderate impairment of either hand warrants a 10 percent rating. Slight impairment warrants a 0 percent rating. 38 C.F.R. § 4.73, Diagnostic Code 5208. The Veteran is deemed to be right handed by his report to the November 2011 VA examiner. As the Veteran is currently in receipt of the maximum rating available for Muscle Group VIII impairment of a minor hand, a higher rating under Diagnostic Code 5308 is not warranted. As noted above, the Veteran is currently evaluated under a hyphenated code, which ultimately rates in accordance with neurological impairment. Under Diagnostic Codes 8515, 8615, and 8715, in the case of complete paralysis, neuritis, or neuralgia of the median nerve, such that the hand is inclined to the ulnar side, the index and middle fingers are more extended than normally, there is considerable atrophy of the muscles of the thenar eminence, the thumb is in the plane of the hand (ape hand), pronation is incomplete and defective, there is absence of flexion of the index finger and feeble flexion of the middle finger, cannot make a fist, index and middle fingers remain extended, cannot flex distal phalanx of thumb, there is defective opposition and abduction of the thumb, at right angles to palm, flexion of the wrist is weakened, and there is pain with trophic disturbances, a 70 percent rating is available for the dominant hand, a 60 percent rating is available for the minor hand. For incomplete paralysis, neuritis, or neuralgia of the median nerve that is severe, a 50 percent rating is available for the dominant hand; a 40 percent rating is available for the minor hand. For incomplete paralysis, neuritis, or neuralgia of the median nerve that is moderate, a 30 percent rating is available for the dominant hand; a 20 percent rating is available for the minor hand. For incomplete paralysis, neuritis, or neuralgia of the median nerve that is mild, a 10 percent rating is available for either the dominant or minor hand. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715. Thus, the current 20 percent rating under Diagnostic Code 8515 contemplates incomplete paralysis, neuritis, or neuralgia of the median nerve that is moderate. To warrant the next higher 40 percent rating, the evidence would have to demonstrate incomplete paralysis, neuritis, or neuralgia of the median nerve that is severe. In the January 2007 claim, the Veteran reported that he has to wear a brace on his left hand; he suffers from extreme problems with being able to grip objects with the left hand, and he cannot hold anything in the left hand for any extended period of time. In correspondence received dated in August 2009, the Veteran wrote that he found the injury to the left hand limits him from performing his job at an optimal level as his coworkers, and he finds himself trying to use the left hand in different positions due to the increased swelling, numbness, and tenderness. This causes hand tremors, which in turn cause the hand to shake. This also causes sharp pain in the hand that leads up through the arm. He reported having difficulties doing basic things, such as clipping finger nails, tying shoes, and holding or grasping a cup. He believes that the injury has prevented him from obtaining several promotional opportunities. The Veteran reported to the November 2011 VA examiner that he has pain in the left hand associated with carrying, pushing, and pulling heavy objects, and sometimes it is hard to tie his shoes. The Veteran's representative asserted in the informal hearing that the Veteran is unable to touch his fingers with his thumb, he has constant pain, and has to wear a brace regularly. Based on the severity of the condition to include his pain level, an increased evaluation is warranted. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran has moderate incomplete paralysis of the left median nerve, and the criteria for an increased rating are not met on the basis of muscular or neurological residuals. Regarding muscle strength, the Veteran has complained of weakness of the left thumb. However, the report of VA examination in November 2011 reveals that strength of grip was rated at 4 out of 5, which was noted as active movement against some resistance, 5 out of 5 being normal. A September 2008 resident physician note reveals complaint of general weakness in the left hand. There was mild thenar atrophy. Grip strength and pinch were weak on the left compared with right, secondary to pain. Range of thumb motion was full. A March 2007 progress note reveals findings of no obvious thenar atrophy, with poor effort on strength testing, rated at 4 out of 5. An EMG in February 2007 reveals findings of no obvious muscle atrophy. There was 5 out of 5 strength for the C5-T1 distribution. Left median and ulnar motor studies revealed normal distal latencies, normal amplitudes and normal conduction velocities. Left median and ulnar sensory studies revealed normal peak latencies and normal amplitudes. Left median and radial numb thumb sensory study revealed normal peak latency and normal amplitude. Despite the normal EMG reports above, the report of VA examination in February 2009 reveals decreased sensation via Weinstein monofilament testing to the thumb, index, and middle fingers, radial aspect of wrist and forearm in a median nerve distribution with decreased sensation in the remainder of hand in a non-dermatomal distribution. Thus, there is clinical evidence of decreased sensation of the left thumb. The Board acknowledges that there have been flare ups of decreased strength of the left thumb. The report of VA examination in March 2010 reveals that there was pain and weakness with severe flare ups every 2 to 3 weeks of usual duration 1 to 2 days. At these times, the left hand was barely functional. The report of VA examination in February 2009 reveals that the Veteran reported decreased strength and dexterity of the left hand, as well as numbness and pain. On testing, there was a significant decrease in grip strength on the left that was possibly pain-related. In essence, the evidence demonstrates normal EMG findings and tests of grip strength that are near normal, with periods of flare ups where thumb strength is markedly decreased. The Board finds that, in light of the Veteran's description of flare ups occurring every 2 to 3 weeks, on balance, the extent of weakness of the left thumb is best described as moderate in degree. In other words, the Board acknowledges that the Veteran has periods of weakness during which strength is impaired to more than a moderate degree; however, these periods are not constant, and are balanced by periods where his strength is near normal. On balance, there is moderate impairment. Regarding motion of the left thumb, the report of VA examination in November 2011 reveals a gap of 1 to 2 inches (2.5 to 5.1 cm.) between the thumb and fingers on flexion, which was the reported point of onset of pain. There was no limitation of extension. There was no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions. There was no additional limitation in range of motion following repetitive-use testing. There was pain associated with movement and weakened movement of the thumb. The report of VA examination in February 2009 reveals a 1-inch gap on thumb to little finger. An October 2009 occupational therapy note reveals that pain was getting worse and the hand was becoming increasingly dysfunctional. The Veteran could oppose the 1st 3 digits. Pain level varied from 4 to 8 out of 10. He reported a 6 out of 10 at the time of the examination. Pain was occurring due to repetitive movement. The Board finds that the Veteran's limitation of motion is consistent with moderate overall impairment under Diagnostic Code 8515. The test results have fluctuated, but, if rated on the basis of limitation of motion alone under Diagnostic Code 5224, these results would warrant a 10 percent rating. Considering the other symptomatology associated with the service-connected disability, the Board finds limitation to this extent to be consistent with moderate overall impairment. The Board acknowledges the Veteran's report of extreme pain. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. Here, the November 2011 VA examiner noted the point of onset of pain. The Board also acknowledges that, at times, pain is present with all motion of the thumb. However, evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. Here, the range of motion measurements set out above were performed despite the presence of pain. Consistent with the Board's finding that the Veteran's left thumb disability results in moderate impairment under Diagnostic Code 8515, the report of VA examination in February 2009 reveals the examiner's finding that the disability was found to have a severe impact on sports, a moderate impact on exercise, a mild impact on chores, recreation, bathing, dressing, and driving, and no impact on traveling, feeding, shopping, toileting, and grooming. The examiner opined that there would be a moderate negative effect on employment of a physical nature, and a mild negative effect on sedentary employment. On balance, the Board finds that an overall moderate impairment is shown. As discussed above, a rating in excess of 20 percent is not warranted under the diagnostic codes for muscle injury or limitation of motion of the thumb. The Board has considered whether a separate rating is warranted for limitation of motion of the left thumb, in addition to muscular or neurological residuals. In this case, limitation of motion and muscular residuals are specifically considered in the criteria for neurological impairment under Diagnostic Code 8515, which include atrophy of the muscles of the thenar eminence, the thumb being in the plane of the hand (ape hand), inability to flex the distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to the palm, and inability to make a fist. Accordingly, separate ratings for limitation of motion and/or muscle impairment are not warranted in addition to the neurological rating. Moreover, the diagnostic code for muscle impairment specifically directs to rate the disability on the basis of limitation of motion. Therefore, separate ratings cannot be assigned under those codes without violating the prohibition against pyramiding. 38 C.F.R. § 4.14 (2012). Finally, regarding neurological and muscle impairment, the Board acknowledges the Veteran's report of left hand and arm symptoms, such as hand tremors that cause the hand to shake, as well as sharp pain in the hand that leads up through the arm and to the shoulder. The claim on appeal does not encompass disability of the left hand and arm. Those issues are addressed in the Board's remand below. Turning to the scar residuals, the Board notes that the schedule for rating disabilities of the skin was amended effective September 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). The October 2008 revisions are applicable to claims for benefits received by VA on or after October 23, 2008. As the Veteran filed his claim for an increased rating in 2007, only the pre-October 2008 version of the schedular criteria is applicable. Nevertheless, the Veteran may request that the RO evaluate his scar under the revised provisions. Under the pre-amended version of Diagnostic Code 7804, a single 10 percent rating is provided for scars that are superficial and painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). In this case, the clinical findings describe one scar that is painful. It is acknowledged that the scar is painful. Accordingly, the weight of the evidence demonstrates that a 10 percent rating is appropriate in this case. That is the maximum rating available on the basis of painful scars. The Board has also considered whether a higher rating is warranted under other diagnostic codes pertinent to scars. The Board finds that Diagnostic Code 7800 applies to scars of the head, face, or neck. In light of the anatomical location of the affected skin in this case, which does not involve the head, face, or neck, Diagnostic Code 7800 is not applicable. Diagnostic Code 7801 is applicable to scars other than head, face, or neck, that are deep or that cause limited motion. Here, the evidence shows, that the scar does not approximate a deep scar. The November 2011 VA examiner found that the scar was not deep. In addition, there is no indication that the scar itself causes limited motion. Moreover, as discussed above, the Veteran is separately rated for limitation of motion of the thumb. Therefore, Diagnostic Code 7801 is not appropriate. Diagnostic Code 7802 describes areas of 144 square inches (929 sq. centimeters) or greater. The November 2011 VA examiner described a single scar that measured 4 centimeters. The February 2009 VA examiner found a scar measuring 5.1 centimeters by 1 centimeter. The February 2007 VA examiner measured a scar that was 5 centimeters by 1 centimeters. Accordingly, that code is not appropriate. Diagnostic Code 7803 applies to superficial and unstable scars. An unstable scar is defined as one where, for any reason, there is frequent loss of covering of skin over the scar. In this case, as specifically found by the November 2011 VA examiner, the evidence demonstrates that the scar is not unstable. The February 2009 VA examiner found no adherence to underlying tissue. There was no skin ulceration or breakdown over the scar. Diagnostic Code 7805 applies to limitation of function. While the November 2011 VA examiner found that the scar causes decreased flexion of left thumb at metacarpophalangeal joint, as set out in detail above, the Veteran is separately rated for limitation of motion of the thumb. The February 2009 VA examiner found no limitation of motion resulting from the scar itself. For these reasons, the Board finds that the weight of the evidence demonstrates that a disability rating in excess of 20 percent for neurological residuals is not warranted, and a disability rating in excess of 10 percent for scar residuals is not warranted. To the extent any higher level of compensation is sought, the preponderance of the evidence is against these claims, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Analysis of Rating for Deviated Septum The current appeal arises from a claim for service connection received at the RO on January 12, 2007. In a July 2009 rating decision, the RO granted service connection for a deviated nasal septum, and assigned a 0 percent initial disability rating, effective January 12, 2007, pursuant to Diagnostic Code 6502. The Veteran appealed the 0 percent rating, and, in a December 2011 rating decision, the RO granted an increased 10 percent rating, effective November 18, 2011, the date of VA examination. Under Diagnostic Code 6502, which specifically encompasses deviation of the nasal septum, a single rating of 10 percent is provided. The 10 percent rating contemplates a 50 percent obstruction of the nasal passage on both sides or a complete obstruction on one side. The February 2009 VA examination on which the grant of service connection was based found there to be a 0 percent obstruction on the left, and a 20 percent obstruction on the right. The diagnosis was nasal septal deviation with mild left obstruction, status post nasal fracture. There were no significant effects on the Veteran's daily activities and a minimal negative effect on physical or sedentary employment. A CT scan of the sinuses was conducted in August 2009. The results show a severe left septal deviation with approximately 90 percent obstruction on the left and 70 percent on the right. A follow-up CT in November 2009 reveals a 90 percent obstruction. Based on these results, the Veteran was offered a nasal septoplasty. The report of VA examination in November 2011 reveals a greater than 50 percent obstruction on each side, but that there was not a complete obstruction of either side. The examiner noted that the deviation did not impact the Veteran's ability to work. Regarding the RO's finding that the November 18, 2011 VA examination was the first evidence establishing the criteria for a 10 percent rating for deviated nasal septum, the Board finds that the August 2009 CT scan demonstrates that the criteria for a 10 percent rating were met more than two years prior to that examination. Moreover, while the February 2009 examination appears to show only a 20 percent obstruction on the right and no obstruction on the left, this estimate was apparently made without the benefit of any imaging, such as the CT scan conducted in August 2009. It is therefore accorded less probative weight than the later findings, all of which show that the criteria for a 10 percent rating are met. To the extent of any remaining reasonable doubt, the Board resolves such doubt in the Veteran's favor and finds that a 10 percent initial rating is warranted prior to November 18, 2011. As the maximum schedular rating is now assigned for the Veteran's deviated nasal septum for the entire period on appeal, the Board finds that a disability rating higher than 10 percent on a schedular basis is not warranted. The Board has considered whether separate ratings are available for each nasal passage; however, Diagnostic Code 6502 appears to consider both passages as affected by a single deviated septum. The Board finds that separate ratings are not contemplated under this diagnostic code. The Board will address extraschedular referral below. For the reasons stated, the Board finds that, while a 10 percent disability rating is warranted prior to November 18, 2011, the weight of the evidence demonstrates that a disability rating in excess of 10 percent for the deviated nasal septum is not warranted for any period on appeal. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Analysis of Rating for Headaches The current appeal arises from a claim for service connection received at the RO on March 13, 2007. In a July 2009 rating decision, the RO granted service connection for headaches and assigned an initial 0 percent rating pursuant to Diagnostic Code 8100, effective March 13, 2007. In a December 2011 rating decision, the RO granted an increased 30 percent rating pursuant to Diagnostic Code 8100, effective November 18, 2011. Under Diagnostic Code 8100, a 50 percent rating is available with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; a 30 percent rating is available with characteristic prostrating attacks occurring on an average once a month over the last several months; a 10 percent rating is available with characteristic prostrating attacks averaging one in 2 months over last several months. Where there are less frequent attacks, a 0 percent rating is for application. 38 C.F.R. § 4.124a, Diagnostic Code 8100. After a review of all of the evidence, the Board finds that an approximate balance of the evidence for and against the criteria for a 50 percent rating for headaches has been reached for the entire period on appeal. In essence, there are two components to the single criterion for a 50 percent rating. The first is the presence of very frequent completely prostrating and prolonged attacks, and the second is resulting severe economic inadaptability. In this case, the report of VA examination in November 2011 reveals the specific finding of the examiner that the Veteran experiences very frequent completely prostrating and prolonged attacks. The report of VA examination in July 2010 reveals the Veteran's report of headaches at least every other day, with duration lasting hours. The report of VA examination in February 2009 reveals that the Veteran reported migraines approximately 3 times a month. Regarding the frequency of attacks, it would appear that they have always exceeded the one per month necessary for a 30 percent rating. The November 2011 examiner reported the Veteran's account that he has 2 headaches a week, mostly on the left side, for which he lays down in a dark room all day and treats with ice packs and nasal spray medicine. The duration of pain is less than 1 day. The Veteran also reported nausea and sensitivity to light and sound during these attacks. The November 2011 examiner found that prostrating attacks were experienced more frequently than once per month. In correspondence received in August 2007, the Veteran reported headaches and migraines 3 or 4 times a month. The report of VA examination in July 2010 reveals the Veteran's report of headaches at least every other day, with duration lasting hours. The report of VA examination in February 2009 reveals that the Veteran reported migraines approximately 3 times a month. Thus, the evidence throughout the period of this claim indicates that the Veteran experiences very frequent completely prostrating and prolonged attacks. Regarding the economic impact of the headaches, the Veteran reported to the November 2011 VA examiner that he was concerned that he would be laid off soon. In the prior 12 months he had called in sick 2 days a week, about 100 days, mostly due to headaches. The report of VA examination in July 2010 reveals the Veteran's report that he had lost 2 weeks from work during the past 12-month period. In correspondence received with the August 2009 VA Form 9, the Veteran reported that the headaches leave him unable to function, and he has to lay down in a dark room and place cold backs on his head. The Veteran's representative asserted in the informal hearing that the Veteran has used all of his sick leave and gone on to using family leave due to calling in twice a week due to his headaches. A July 2009 treatment note reveals that the Veteran was in the emergency room recently and reported an aura followed by an intense frontal headache with photophobia and nausea. It was noted that he cannot work or drive with a headache. In sum, there is significant evidence demonstrating severe economic inadaptability. The Board acknowledges the report of VA examination in February 2009, which reveals that, when present, this condition would have a moderate negative effect on physical or sedentary employment. In light of the other findings, discussed above, the Board finds that an approximate balance of the evidence for and against the criteria for a 50 percent rating for headaches has been reached. With resolution of reasonable doubt in the Veteran's favor, the Board finds that the criteria for a 50 percent disability rating for headaches are met for the entire period of this appeal. As a 50 percent rating is the maximum rating available for headaches, the Board finds that discussion of a higher schedular rating is not warranted. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, 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. 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. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected left thumb neurological, muscle, and scar residuals, left wrist disability, headaches, and deviated nasal septum. The criteria for the deviated nasal septum specifically provide for symptoms of obstructed nasal passages, up to and including complete obstruction on either side. In this case, the Veteran does not have complete obstruction of either side. Therefore, it would appear that the rating schedule encompasses his symptomatology entirely. The criteria for headaches specifically provide for symptoms of head pain and incapacitation, up to and including severe economic inadaptability. The criteria for neurological and muscle injuries to the left thumb specifically contemplate symptoms of pain, numbness, weakness, fatigue, and limited motion. Moreover, higher ratings are available where severe incomplete paralysis or complete paralysis are shown. The criteria for scars specifically contemplate a painful scar. Higher ratings are available where other manifestations of scars are shown, such as large, unstable, deep, or disfiguring scars. The criteria for the Veteran's left wrist disability contemplate limited motion of the wrist, as well as painful motion and weakness. The criteria specifically provide for ratings based on the presence of arthritis, and limitation of motion, including due to pain and other orthopedic factors. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. Such factors are explicitly part of the schedular rating criteria. Indeed, the rating criteria clearly contemplate that the 10 percent rating is adequate to compensate any limitation of motion that is short of ankylosis, or complete union of the bone across the joint. Because in each case the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Concerning the appeals for higher initial ratings, because they arise from the Veteran's disagreement with the initial evaluations following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the CAVC have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). In this case, the Veteran submitted his increased rating claim for the left thumb in January 2007. He was sent a letter in February 2007 which advised him of the information and evidence necessary to substantiate the claims. That letter also advised him as to how disability ratings and effective dates were assigned. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Since the February 2007 letter was sent to the Veteran prior to the initial adjudication of the claims in January 2008, there exists no error in the timing of this notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In short, VA has complied with its duty to notify the Veteran in this case. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's written assertions. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of his left thumb, deviated nasal septum, headaches, and left wrist. These examinations were adequate because each was performed by a medical professional based on solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. Moreover, the examiners included findings that address the pertinent rating criteria. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). ORDER A disability rating for arthritis of the left wrist in excess of 10 percent is denied. A disability rating for residuals of a left thumb laceration in excess of 20 percent is denied. A disability rating for scar of the left thumb in excess of 10 percent is denied. Prior to November 18, 2011, a 10 percent disability rating, but not higher, for deviated nasal septum is granted. Since November 18, 2011, a disability rating for deviated nasal septum in excess of 10 percent is denied. Prior to November 18, 2011, a 50 percent disability rating, but not higher, for headaches is granted. Since November 18, 2011, a 50 percent disability rating, but not higher, for headaches is granted. REMAND A remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's claims of (1) entitlement to service connection for a pain disorder, (2) entitlement to service connection for a left hand disability, (3) entitlement to service connection for a left arm disability, and the intertwined claim of (4) entitlement to TDIU. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002 & Supp. 2011); 38 C.F.R. § 3.159(c), (d) (2012). Service Connection Claims The Veteran is service connected for adjustment disorder with depressed mood. He has also been diagnosed with a pain disorder. A March 2010 VA mental health clinic medication review note reveals an Axis I diagnosis of pain disorder with psychological factors versus other somatic disorders. The record is currently unclear as to the manifestations of the diagnosed pain disorder. Moreover, there is no opinion of record as to whether the Veteran's diagnosed pain disorder is related to service or to any service-connected disability. An opinion by an April 2009 VA examiner acknowledged the pain disorder, but the opinion was limited to the etiology of headaches. The issues of entitlement to service connection for disabilities of the left hand and arm appear to have arisen from the Veteran's description in his January 2007 claim that he experiences pain in his left hand and arm. The Veteran wrote that he suffers from a tremendous amount of pain in the left hand that keeps him from being able to use the left hand and arm. He also reported arthritis in the hand and "shrapnel" or some type of metal that was caused from the injury or that was left from the surgery. In the VA Form 9, the Veteran reported hand tremors, swelling in the elbow, and stiffness in the shoulder due to the left thumb disability. While the Veteran phrased the claim as one for an increased rating for the service connected left thumb disability, the record does contain additional diagnoses that may impact the left hand and arm. Most notably, the April 2009 VA examination reveals a rule-out diagnosis of reflex sympathetic dystrophy to account for the Veteran's complaints of left upper extremity pain, swelling, sensitivity, and coldness. The examiner noted that reflex sympathetic dystrophy typically is associated with a variety of traumatic events, and that the location and extent of tissue trauma does not directly correlate with the location and severity of the pain, such as is the case with this veteran. While service connection for a left wrist disorder was granted in large part due to this report, the report appears to encompass additional left upper extremity impairment. The examiner did not include a conclusive etiology opinion regarding reflex sympathetic dystrophy, but limited his opinion to claimed headaches, which he found to be related to the service-connected left thumb disability. In addition, X-rays, such as in December 2006, reveal minimal arthritic changes with small metallic foreign bodies in the first and second fingers. The report of VA examination in February 2009 reveals a 2 mm metallic foreign body within the thenar eminence, questionable juxta-articular demineralization, traumatic mononeuropathy, median nerve, left hand/wrist/forearm, and myofascial pain syndrome. The grants of service connection currently encompass muscular/neurological and scar residuals of the left thumb, and arthritis and juxta-articular demineralization of the left wrist. Service connection does not currently extend to any other disorder of the left arm or hand; however, there is competent evidence, in the form of the medical reports above, and the Veteran's assertion of additional left hand and arm disabilities that is not currently recognized. This case presents certain medical questions which cannot be answered by the Board. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). These questions concern the relationship, if any, between the Veteran's diagnosed pain disorder and his military service and/or a service-connected disability. These questions must be addressed by an appropriately qualified medical professional. See Charles v. Principi, 16 Vet. App. 370 (2002); see also 38 C.F.R. § 3.159(c)(4) (2012) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). In disability compensation (service connection) claims, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the factor of relationship of current disability to service, the CAVC has indicated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and a veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83; see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service). TDIU The separate issue of entitlement to TDIU is inextricably intertwined and the proposed development will encompass that issue. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, the issues of entitlement to service connection for a pain disorder, entitlement to service connection for a left hand disability, entitlement to service connection for a left arm disability, and entitlement to TDIU are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA medical evaluation or evaluations to determine the nature and etiology of his diagnosed pain disorder, and his claimed disabilities of the left hand and arm. The relevant documents in the claims file should be made available to the VA clinician assigned to conduct the evaluation(s). The VA clinician should identify all current diagnoses of the left hand and arm. The clinician should specifically address the validity of the diagnoses of a pain disorder and reflex sympathetic dystrophy. For each diagnosis, the clinician is requested to offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that the diagnosed disability is causally or etiologically related to the Veteran's active service or to any service-connected disability. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. If the requested medical opinion cannot be given, the VA clinician should state the reason(s) why. 2. Readjudicate the remanded claims of entitlement to service connection for a pain disorder, a left hand disability, a left arm disability, and entitlement to TDIU. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case and an appropriate time period for response. The case should then 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 matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These issues must be afforded expeditious treatment. The law requires that all issues remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs