Citation Nr: 1308732 Decision Date: 03/14/13 Archive Date: 03/25/13 DOCKET NO. 08-16 752 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial, compensable rating for carpal tunnel syndrome of the right upper extremity prior to September 11, 2012. 2. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome of the right upper extremity from September 11, 2012. 3. Entitlement to an initial, compensable rating for carpal tunnel syndrome of the left upper extremity prior to September 11, 2012. 4. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome of the left upper extremity from September 11, 2012. 5. Entitlement to an initial disability rating in excess of 10 percent for reflux esophagus, also diagnosed as ?gastroesophageal reflux disease (GERD). REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from October 2002 to November 2006. This appeal to the Board of Veterans' Appeals (Board) arose from a July 2007 rating decision in which the RO, inter alia, granted service connection for lumbosacral strain with degenerative disc disease, neurological impairment of the left lower extremity, reflux esophagus, carpal tunnel syndrome of the right upper extremity, and carpal tunnel syndrome of the left upper extremity. The Veteran was assigned an initial 10 percent rating, each, for lumbosacral strain with degenerative disc disease and for neurological impairment of the left lower extremity, and an initial 0 percent (non-compensable) rating, each, for reflux esophagus, carpal tunnel syndrome of the right upper extremity, and carpal tunnel syndrome of the left upper extremity. Each award was made effective November 24, 2006 (the day after the date of the Veteran's discharge from service). In July 2007, the Veteran filed a notice of disagreement (NOD) with the assigned disability ratings. A statement of the case (SOC) was issued in April 2008, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in May 2008. The RO issued a supplemental SOC in August 2008 and RO forwarded the claims file to the Board for appellate review. In January 2010, the Board denied the claims for initial ratings in excess of 10 percent for lumbosacral strain with degenerative disc disease and for neurological impairment of the left lower extremity. The Board also remanded the remaining claims on appeal to the RO, via the Appeals Management Center (AMC), for additional development and consideration. In May 2011, the AMC issued a rating decision granting an initial 10 percent disability rating for reflux esophagus. In April 2012, the AMC issued a supplemental SOC reflecting continued denial of the claims for initial compensable evaluations for carpal tunnel syndrome of the bilateral upper extremities. The AMC issued a September 2012 supplemental SOC reflecting denial of an initial rating in excess of 10 percent for reflux esophagus and continued denial of the claims for initial compensable evaluations for carpal tunnel syndrome of the bilateral upper extremities. No additional evidence was subsequently added to the claims file, but the RO issued a later September 2012 rating decision granting 10 percent disability ratings, each, for carpal tunnel syndrome of the left upper extremity and carpal tunnel syndrome of the right upper extremity, effective September 11, 2012. The Veteran's appeal was re-certified to the Board in November 2012 and the claims file was returned to the Board for further appellate review. Although, following the Board's remand, the AMC assigned an initial 10 percent rating for reflux esophagus, and the RO assigned a 10 percent rating each for carpal tunnel syndrome of the upper right extremity and for carpal tunnel syndrome of the upper left extremity from September 11, 2012, as higher ratings for each disability are available before and after this date, and the Veteran is presumed to seek the maximum benefit available for a disability, the appeal as to those specific disabilities now encompasses the first, second, third, and fourth matters set forth on the title page. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board's decision on the claims for higher ratings for carpal tunnel dydrom for each upper extremity is set forth below. The matter of entitlement to an initial disability rating in excess of 10 percent for reflux esophagus is addressed in the remand following the order; this matter is being remanded to the RO, via the Appeals Management Center in Washington, DC. VA will notify the Veteran when further action, on his part, is required. As a final preliminary matter, the Board notes that a February 2013 letter from the RO to the Veteran appears within the virtual (electronic) portion of his claims file. The letter reflects that the Veteran submitted an NOD to the RO in regard to the effective dates of the 10 percent ratings assigned in the October 2012 rating decision for his carpal tunnel syndrome of the bilateral upper extremities. The letter also states that the RO has "taken" those issues under appeal and will "try to resolve [the] disagreement through the post-decision review process." However, as noted immediately above, the issues of the Veteran's entitlement to higher disability ratings for carpal tunnel syndrome of the bilateral upper extremities, both prior to, and after, September 11, 2012, are currently within the Board's appellate jurisdiction. 38 C.F.R. § 19.38 (2012). As such, these matters are not properly before the Board. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each matter herein decided have been accomplished. 2. From the November 24, 2006, effective date of the award of service connection through September 10, 2012, the Veteran's carpal tunnel syndrome of the upper right extremity was manifested by overall mild disability, including some decreased motion and grip strength, with complaints of pain with stiffness and numbness. 3. Sincethe September 11, 2012, the date of the most recent VA examination, the Veteran's carpal tunnel syndrome of the upper right extremity has been manifested by complaints of increased pain and moderate symptoms of loss of sensation, loss of strength and decreased manual dexterity. 4. From the November 24, 2006, effective date of the award of service connection through September 10, 2012, the Veteran's carpal tunnel syndrome of the upper left extremity was manifested by mild disability, including some decreased motion and grip strength, with complaints of pain with stiffness and numbness. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent disability rating for carpal tunnel syndrome of the right upper extremity are met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.27, 4.124a (Diagnostic Code 8515) (2012). 2. The criteria for a 30 percent disability rating for carpal tunnel syndrome of the right upper are met from September 11, 2012. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.27, 4.124a (Diagnostic Code 8515) (2012). 3. The criteria for an initial 10 percent disability rating for carpal tunnel syndrome of the left upper extremity are met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1 , 4.7, 4.20, 4.27, 4.124a (Diagnostic Code 8515) (2012). 4. The criteria for a rating in excess of 10 percent for carpal tunnel syndrome of the left upper extremity are not met from September 11, 2012. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.27, 4.124a (Diagnostic Code 8515) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 -23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed.Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a January 2007 pre-rating letter provided notice to the Veteran regarding what information and evidence was needed to substantiate the initial claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. This letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. Post rating, the April 2008 SOC, as well as a June 2008 letter, set forth the pertinent criteria for rating the disabilities (the timing and form of this notice suffices, in part, for Dingess/Hartman). Nonetheless, after issuance of above-described notice, and opportunity for the Veteran to respond, supplemental SOCs issued in August 2008 and September 2012 reflect readjudication of the claims. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of service treatment records, VA treatment records, evidence from the Social Security Administration (SSA), and the reports of VA examinations conducted in March 2007, April 2010, December 2011, and September 2012. Also of record and considered in connection with the appeal are various statements provided by the Veteran. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the paperless claims processing system revealed additional medical evidence that has been carefully reviewed by the Board. The Board finds that no additional RO action to further develop the record in connection with any of these claims, prior to appellate consideration, is required. Although the claims file reflects that the Veteran reported in his May 2008 substantive appeal that he "had to seek medical attention" for his carpal tunnel disabilities, he did not respond to subsequent, June 2008 or March 2010, letters requesting that he either submit any additional evidence or identify such evidence so that VA could obtain it on his behalf. VA's duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). See also Swann v. Brown, 5 Vet. App. 229, 233 (199). VA treatment notes and examination reports are associated with the record and neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the specific claims on appeal. Under the circumstances, the Board finds that the RO has undertaken sufficient and appropriate development action and that no further action in this regard is warranted. The Board further notes that these claims were remanded in January 2010 for the RO to assist the Veteran with evidentiary development, to include assisting him with the collection of any outstanding records and for him to undergo a VA examination. Although the Veteran has not advised VA of any outstanding records, the requested development was accomplished on remand, so there was compliance with these remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no violation under Stegall v. West, 11 Vet. App. 268, 271 (1998) when the examiner made the ultimate determination required by the Board's remand). As mentioned, the Veteran was afforded VA examinations with resulting medical opinions in March 2007, April 2010, December 2011, and September 2012. Although the April 2010 VA examination does not explicitly state that the claims file was reviewed and the September 2012 examination report reflects that the examiner reviewed treatment records rather than the entire claims file, the Board finds that the VA examinations and accompanying opinions are adequate to decide the issues as they are predicated on interviews with the Veteran and current physical examinations. The opinions proffered considered evidence pertinent to the current (at the time of each examination) severity of his disabilities and provided a complete rationale, relying on the results of interview, examination, and any records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination has been met. 38 C.F.R. § 3.159(c)(4) . In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed.Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the award of service connection and consideration of the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126. Historically, the Veteran was granted service connection for carpal tunnel syndrome of the upper left and right extremities in a July 2007 rating decision. A 0 percent (noncompensable) rating was assigned, effective November 24, 2006, the day following his discharge from active duty service. The Veteran's disability has been evaluated under Diagnostic Codes 8599-8515, indicating that it has been rated by analogy to other nerve disabilities in the rating schedule. Pursuant to 38 C.F.R. § 4.27, when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: The first 2 digits will be selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be "99" for all unlisted conditions. 38 C.F.R. § 4.27 (2012). Hyphenated diagnostic codes are used when a rating under one Diagnostic Code requires use of an additional Code to identify the basis for the evaluation assigned. Id. Here, Code 8515 was used to identify the basis for the evaluation. Code 8515 is used to rate paralysis of the median nerve. Under Diagnostic Code 8515, for rating paralysis of the median nerve, mild incomplete paralysis of the median nerve in the major or minor extremity warrants a 10 percent rating. For the major extremity, moderate incomplete paralysis warrants a 30 percent rating and severe incomplete paralysis warrants a 50 percent rating. For the minor extremity, moderate incomplete paralysis warrants a 20 percent rating and severe incomplete paralysis warrants a 40 percent rating. The words "mild," "moderate," and "severe" as used in the Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6 . 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 in the major extremity and a 60 percent rating in the minor extremity. 38 C.F.R. § 4.124a. The pertinent medical evidence of record consists of the Veteran's lay statements, service records, SSA records, VA treatment records, and reports of VA examination. In November 2005, while the Veteran was still on active duty, a neurological test conducted to evaluate a back disability revealed a positive compression test at the bilateral wrists. He was scheduled for a consultation for wrist splints. Subsequently, he was diagnosed with mild bilateral carpal tunnel syndrome and advised to wear wrist splints. He complained of pain and numbness at the bilateral wrists. Following service, he filed for service connection in January 2007. His claims form reflected that he had not received any treatment since service. He was afforded a VA examination in March 2007. The examiner observed that he experienced pain in the dorsum and volar surfaces of both wrists with numbness into the dorsum of the hand. The examiner noted that the Veteran was right-handed and did not experience any arthritis. Dorsiflexion of the wrists was 70 degrees bilaterally and palmar flexion was 80 degrees bilaterally. The examiner diagnosed bilateral carpal tunnel syndrome. The RO issued a July 2007 rating decision granting service connection for carpal tunnel syndrome of the bilateral upper extremities, but assigning a non-compensable (0) disability evaluation. In a July 2007 statement to VA, the Veteran wrote that, although he wore wrist splints at night so his wrists were pain-free in the morning, pain returns by mid-day. He stated that when the pain returns, his hands and wrists start to feel numb, occasionally necessitating day-time use of wrist splints. In a May 2008 statement, he reported that his symptoms had been consistently present. He was afforded another VA examination in April 2010. The examination report reflects that the Veteran told the examiner began experiencing numbness and tingling in the bilateral hands while in the military and those symptoms, as well as pain radiating into his forearms, had persisted. The report also reflects that the Veteran only treatment had been the use of wrist splints. The Veteran reported pain in both wrists, stiffness in the left, and mild, weekly flare-ups lasting one (1) to two (2) days. Upon physical examination, the examiner determined that the wrists appeared normal. Left and right dorsiflexion was measured to 55 degrees. Left and right palmar flexion was measured to 85 degrees. Left ulnar deviation was 30 degrees and right ulnar deviation as well as bilateral radial deviation was measures at 20 degrees. There was no additional loss of range of motion upon repeated movements. The examiner diagnosed bilateral carpal tunnel syndrome without significant effects on the Veteran's usual occupation. SSA arranged for the Veteran to undergo a disability evaluation in June 2011. The Veteran informed the disability examiner that he experienced carpal tunnel syndrome. Upon testing, Tinel's and Phalen's tests were positive and the Veteran reported experiencing pain upon percussion of the anterior wrists. Left and right dorsiflexion and palmar flexion were measured to 50 degrees. Left and right ulnar deviation were 25 degrees and bilateral radial deviation was 20 degrees. In November 2011, the Veteran was afforded a VA electrodiagnostic consultation to evaluate for carpal tunnel syndrome. The Veteran reported experiencing pain and numbness of the bilateral hands, right worse than left, radiating from the wrists to 1/3 of the way up the forearms. He also reported decreased grip strength. Upon physical examination, the physician noted four (4) out of five (5) wrist extension and flexion, grip strength, and intrinsic muscle strength as well as diminished sensation to light touch in the right hand, as compared to left. There was a positive Tinel's sign at both wrists as well as positive Phalen's with numbness spreading into the fingers of both hands in a median distribution. However, electrodiagnostic studies were all normal. The physician noted no electrodiagnostic evidence of carpal tunnel syndrome, radiculopathy, or other denervation. Although the physician noted that the cause of the Veteran's symptoms was unclear, she stated that they could be caused by intermittent nerve compression not severe enough to cause demyelination or axonal injuries. She stated that decreased grip strength could be due to disuse or pain. She advised occupational therapy as well as replacing his wrist braces. In December 2011, the Veteran was afforded another VA examination. The examiner noted review of the claims file and of the medical record, reported that the Veteran's carpal tunnel syndrome had been treated by splints, but reported that the progress had been progressively worse. The Veteran specifically reported pain to the dorsum of the wrists with occasional radiation to the second and third digits. He also reported difficulty gripping objects, on the right side more than the left side. A sensory examination of the bilateral upper extremities was normal as was a finger reflex test. Electrodiagnostic test results were again noted to be normal. The examiner stated that the examination was unremarkable except for tenderness to palpation to the extensor tendon of the right long finger with increased pain on forced flexion of the wrist. On the basis of the physical findings, the examiner stated that the Veteran did not (clinically or diagnostically) have carpal tunnel syndrome and, instead, diagnosed tendonitis of the right wrist, caused by overuse. The examiner noted that the pain associated with the right wrist increased with use. Despite the December 2011's diagnostic opinion, subsequent therapy notes reflect that he continued to receive treatment for 'suspected' intermittent median nerve compression. In April 2012, he was prescribed a thumb splint as well as a wrist splint due to a reported increase in bilateral thumb pain occurring over the last year. The Veteran reported that the pain particularly increased after writing or using a computer. His bilateral grip strengths were noted to be significantly below normal, but the Veteran reported that he was not gripping as hard as he could due to pain. No muscle atrophy was observed that would "substantiate such worsened hand grip." At a general medical VA examination in May 2012, the Veteran reported experiencing weakness in the bilateral upper extremities as well as paresthesias in the bilateral hands. A detailed motor examination was conducted. The Veteran's wrist flexion and extension were measured at five (5) out of 5, with thumb opposition at four (4) out of 5. A note to the examination states that a 5 indicates active movement against full resistance, a 4 indicates active movement against some resistance, a three (3) as active movement against gravity, a two (2) as active movement when gravity eliminated, a one (1) as palpable or visible contracture, and a zero (0) as total paralysis. The Veteran was not afforded another VA examination for the specific purpose of evaluating the extent of his wrist disabilities again until September 2012. At that time he reported that his symptoms had worsened to the extent that he was having difficulty opening bottles and determining how much pressure he was applying to objects he was holding. He also informed the examiner that he was having some difficulty with dropping items from both hands. He reported using daily paraffin baths, warm gloves, and pain medication to treat his symptoms in addition to wearing wrist splints. He reported his symptoms as pain, numbness, tingling, and fatigability of the upper bilateral extremities with weakness and paresthesias. Upon sensory testing, the bilateral upper extremities were both normal to pinprick, but the right was decreased at the radial aspect of the distal end of the forearm. Both had decreased sensation to light touch - on the right side at two (2) fingers (the middle and ring finger tips) and, on the left side, at the middle finger tip. Detailed motor examination revealed wrist flexion and extension, as well as thumb opposition, at four (4) out of five (5). No muscle atrophy was noted. The examiner diagnosed compression of the median nerves of the bilateral wrists, mildly disabling on the left side and moderately disabling on the right. The examiner described the functional effects of the disability as decreased manual dexterity, problems with lifting and carrying, decreased strength, and pain - preventing repetitive motions such as keyboarding and use of vibrating or pounding tools. Considering the pertinent evidence in light of applicable rating criteria and other legal authority noted above, the Board finds that the bilateral wrist disabilities, currently rated as carpal tunnel syndrome, but recently diagnosed as compression of the median nerve of the wrists, have been manifested by complaints of pain and numbness and associated functional loss consistent with overall mild incomplete paralysis of the median nerve, warranting a 10 percent rating under Diagnostic Code 8515, since the effective date of service connection. However, based on the findings of the September 2012 VA examiner, the Board finds that the right wrist disability has been, since the date of that examination, manifested by symptoms consistent with overall moderate incomplete paralysis of the median nerve, warranting a 30 percent rating under Diagnostic Code 8515. Hart, 21 Vet. App. at 509-10. Although the findings on the March 2007 VA examination do not demonstrate loss of function, the Veteran's service records reflect pain and numbness requiring the use of splints. He also provided lay testimony in July 2007 and May 2008 statements that the severity of symptoms remained constant after he was discharged from active duty; and he is competent to report his symptoms. See, e.g., Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Further, the April 2010 VA examiner described his symptoms as pain and stiffness resulting in decreased activity and noted that the symptoms had been stable since onset. The December 2011 VA examiner noted that the Veteran did not have any wrist disability other than tendonitis of the right wrist, but VA specialist treatment notes - specifically the consultation report by the November 2011 physiatrist and subsequent therapy notes - reflect otherwise. Both the December 2011 examiner and the November 2011 physiatrist who conducted his electrodiagnostic testing observed that the Veteran reported worsening symptoms. The physiatrist specifically noted radiating pain and numbness, worse on the right side than the left side, as well as decreased grip strength. Despite the Veteran's reports of worsening, the evaluations by the physiatrist and the December 2011 examiner revealed pain and numbness resulting in a slightly (4/5) decreased grip strength, wrist flexion, and wrist extension, but no evidence of any muscle paralysis or atrophy, and no evidence of any limitation of finger movement or weakened (as opposed to painful) wrist flexion. The physiatrist's report indicates that the likely cause of the Veteran's symptoms is median nerve compression that is intermittent, position dependent, and "not severe enough to cause" measurable nerve damage. The Board finds that the November and December 2011 clinical findings continue to reflect an overall mild median nerve disability - the Veteran has been able to make a fist, move his fingers and hands, and there have been no trophic changes and no electrodiagnostic evidence of any disability. While an examiner's assessment of the severity of a disability is not dispositive, the Board also notes that no medical professional, prior to September 2012, had assessed either of his wrist disabilities as more than mild in nature. A 10 percent disability rating is appropriate for a mild median nerve disability of either the dominant or non-dominant side, under 38 C.F.R. § 4.124a, Diagnostic Code 8515. Although the Veteran's complaint of experiencing worse symptoms on his right, than on his left, side was documented before the September 2012 VA examination, before that examination, no examiner had opined, or made clinical findings that, one side was worse than the other. Further, there was no clinical evidence that, even if one side was worse than the other, that either side was more than mild in severity. However, the September 2012 examination report reflects that the Veteran's median nerve disability on the right side is manifested by decreased ability to feel pain and some loss of sensation on his right middle and ring fingers, but only affects one (1) finger on the left side. The examiner determined that the disability resulted in the same disabling effects on both sides - decreased grip, decreased dexterity, and problems lifting and carrying objects - but was more severe on the right side. He opined that, based on his clinical findings, the right-sided disability was moderate in severity, but the left-side disability was mild in severity. On the basis of these findings, the Board finds that a 30 percent disability rating, reflecting moderate median nerve disability of a dominant hand, is appropriate from the date of the September 11, 2012 VA examination. The Board further finds that no higher rating is assignable under any other potentially applicable provision of VA's rating schedule. As noted, various examiners and other health care professionals have measured different ranges of motion for the Veteran's wrists. However, under the schedule of ratings of the musculoskeletal system, a 10 percent rating is not warranted unless there is dorsiflexion of less than 15 degrees and a higher rating is not warranted unless there is ankylosis of the joint at 20 to 30 degrees of dorsiflexion. 38 C.F.R. § 4.71a, Diagnostic Codes 5214, 5215. Here, there is no evidence of ankylosis and the Veteran's wrist dorsiflexion has never measured at 30 degrees or less. Similarly, a rating based on limited motion of the index or long finger would not result in an evaluation greater than 10 percent and rating based on limited motion of the ring or little finger would not result in a compensable rating. See Diagnostic Codes 5229, 5230. Furthermore, as no ankylosis of the fingers has been demonstrated, a rating under Diagnostic Codes 5216-5223 or Diagnostic Codes 5225-5227 is not warranted. Moreover, loss of use of either hand simply has not been shown. The Board notes that clinical evidence accumulated over the course of the Veteran's appeal reflects a change in diagnosis from carpal tunnel syndrome of the bilateral wrists to compression, intermittent, of the median nerve of the bilateral wrists. However, as the Veteran's carpal tunnel disabilities have historically been rated under the diagnostic code applicable to disabilities of the median nerve, the Board finds that the assigned code (38 C.F.R. § 4.124a, Diagnostic Code 8515) remains most appropriate given the clinical findings. In adjudicating the claims for higher ratings, the Board has, in addition to the medical findings and assessments, considered the Veteran's reported symptoms, to include pain, which he is certainly competent to assert. See, e.g., Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 469. Also as indicated, however, the criteria for higher ratings for the disabilities under consideration require specific medical findings, which the Veteran does not have the appropriate training or expertise to render. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Thus, although considered, the Veteran's own assertions are not considered more persuasive than the motor and sensory testing results and other pertinent clinical findings of record. In summary, the Board finds that the Veteran's left carpal tunnel syndrome, also diagnosed as median nerve compression, has been manifested by pain and numbness resulting in functional loss consistent with overall mild incomplete paralysis of the median nerve, warranting a 10 percent rating under Diagnostic Code 8515, since the effective date of service connection. The Board also finds that the Veteran's right carpal tunnel syndrome, also diagnosed as median nerve compression, has been manifested by pain and numbness resulting in functional loss consistent with overall mild incomplete paralysis of the median nerve, warranting a 10 percent rating under Diagnostic Code 8515, from the effective date of service connection to September 11, 2012. The Board finds that the clinical findings pertinent to the right wrist at the September 11, 2012 VA examination are consistent with overall moderate incomplete paralysis of the right median nerve, warranting a 10 percent rating under Diagnostic Code 8515. The above determinations are based upon consideration of applicable provisions of VA's rating schedule. Additionally, the Board finds that at no point pertinent to this appeal have the disabilities under consideration been shown to be so exceptional or unusual to warrant the assignment of any higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the April 2008 SOC). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disabilities with the established criteria provided in the rating schedule for the disabilities. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned ratings are therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the schedular rating criteria are adequate to rate the disabilities under consideration. Diagnostic Code 8515 contemplates the symptoms experienced by the Veteran and more symptoms. Specifically, the Veteran's pain, decreased wrist flexion, loss of manual dexterity, loss of strength, and loss of sensation are all accounted for by the rating criteria. The criteria further encompass symptoms, not experienced by the Veteran, such as complete paralysis, "considerable" muscle atrophy, pain with trophic changes, inability to flex fingers, forced extension of fingers, and inability to make a fist. Here, the rating schedule more than fully contemplates the symptomatology described by the Veteran and provides for ratings higher than that assigned for more significant impairment (i.e. atrophy, inability to flex, inability to extend). Although he has complained of pain with certain activities, difficulty holding objects, and occasionally dropping objects, the rating criteria encompass pain so extreme as to result in trophic change as well as paralysis and flexion/contracture symptoms that would consistently prevent any holding of objects. A comparison between the symptomatology of the claimant's disability with the established criteria provided in the rating schedule reveals that his disability picture is adequately addressed by the rating schedule. As such, the assigned ratings are adequate and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96; Thun, 22 Vet. App. 111. The Board also notes, however, that, in certain circumstances, a claim for total disability rating based on individual unemployability due to service-connected disability (TDIU) may be considered a component of a claim for higher rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU may be granted where a Veteran's service connected disability(ies) is/are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2012). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Although the evidence of record reflects that the Veteran is currently employed, he has presented evidence of unemployment during the pendency of his appeal. He specifically filed a claim of entitlement to a TDIU in February 2010. However, his TDIU claims form makes clear that he was not contending that carpal tunnel syndrome, alone or in combination with other service-connected disabilities, rendered him unemployable. Further, the record reflects that the RO issued an October 2012 rating decision denying entitlement to a TDIU and the Veteran has not appealed that denial. As such, and on these facts, the Board finds that no TDIU claim, pursuant to Rice and Roberson, has been raised in connection with the claims for higher rating currently on appeal. ORDER An initial 10 percent disability rating for carpal tunnel syndrome of the right upper extremity (median nerve compression of the right wrist) is granted. A 30 percent disability rating for carpal tunnel syndrome of the right upper extremity (median nerve compression of the right wrist) from September 11, 2012 is granted. An initial 10 percent disability rating for carpal tunnel syndrome of the left upper extremity (median nerve compression of the left wrist) is granted. A rating in excess of 10 percent for carpal tunnel syndrome of the left upper extremity (median nerve compression of the left wrist) from September 11, 2012 is denied. REMAND The Board's review of the claims file reveals that further RO action in this appeal is warranted, even though such will, regrettably, further delay an appellate decision on the matter of the Veteran's entitlement to an increased disability evaluation for reflux esophagus. The September 2012 VA examination included an evaluation of the Veteran's reflux esophagus, also diagnosed as GERD. The report reflects that during the gastrointestinal portion of the examination, the Veteran reported experiencing melena. The examiner noted that he was "currently undergoing work up for melena." As melena is a symptom referenced within the schedule of ratings for disabilities of the digestive symptom, both within the criteria of the disability code currently used to rate his GERD and elsewhere in the schedule, evidence of such a work-up is pertinent to his claim. 38 C.F.R. § 4.114, Diagnostic Codes 7306, 7346. Unfortunately no records of any such work-up appear in the claims file and the last treatment note within the claims file that contains a reference to GERD is dated May 8, 2012, which is prior to the conduct of the examination. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The RO should obtain from the Salisbury VAMC and Hickory community-based outpatient care clinic (CBOC) all outstanding records of relevant VA evaluation and/or treatment of the Veteran for association with the claims file. The RO should follow the current procedures prescribed in 38 C.F.R. § 3.159(c) as regards requests for records from Federal facilities. The RO should also give the Veteran another opportunity to present information and/or evidence pertinent to the claim on appeal. The RO's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A § 5103(b)(1) (West 2002); but see 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2012). The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the all matters on appeal. The RO's adjudication of the claim for an increased rating for reflux esophagus (or GERD) should include consideration of whether "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found), pursuant to Hart (cited above), is appropriate Accordingly, this matter is hereby REMANDED to the RO, via the AMC, for the following actions: 1. Obtain from the Salisbury VAMC and Hickory CBOC outstanding, pertinent records of evaluation and/or treatment of the Veteran generated after May 8, 2012. The RO must follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claims on appeal that is not currently of record. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If he responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 5. After completing the requested action, and any additional notification and/or development deemed warranted, adjudicate the matter on appeal in light of pertinent evidence (to particularly include all that added to the record since the RO's last adjudication of the claim) and legal authority (to include whether any staged rating of the disability, pursuant to Hart (cited above) is appropriate). 6. If the benefit sought on appeal remains denied, the RO must furnish to the Veteran and his representative an appropriate supplemental SOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs