Citation Nr: 1310331 Decision Date: 03/27/13 Archive Date: 04/09/13 DOCKET NO. 10-27 853 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent for sensory neuropathy of the left (minor) hand with degenerative joint disease of the 5th interphalangeal joint. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1964 to March 1966. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. By way of background, a rating decision dated October 2006 granted service connection for degenerative joint disease (DJD) with sensory neuropathy of the left (minor) hand, assigning a 10 percent rating. Within one year of this determination, the Veteran did not express disagreement with the disability evaluation, nor was any relevant new and material evidence, medical or lay, physically or constructively received by VA prior to the expiration of the appellate period. 38 U.S.C.A. § 7105 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.156(b); 20.201 (2012); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011). As such, the October 2006 decision became final. In June 2011, the Board remanded the case for additional development. It now returns for further appellate review. The issue of entitlement to a TDIU was not certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the evidence suggests that the Veteran may be unemployable due to symptoms of his service-connected disability, the issue of entitlement to a TDIU has been raised, is within the jurisdiction of the Board, and has been captioned above as an issue in appellate status. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran is right-hand dominant. 2. For the entire appeal period, the Veteran's sensory neuropathy of the left hand has been productive of no more than moderate incomplete paralysis of the median nerve. 3. For the entire appeal period, the Veteran has exhibited limitation of motion of the little finger of the left hand. 4. The regulations do not provide for a compensable evaluation for limited motion of the little finger. CONCLUSION OF LAW For the entire appeal period, the criteria for an evaluation of 20 percent, but no higher, for the left hand disability have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.124a, Diagnostic Code 5010-8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice requirements apply to all five elements of a service connection claim, including Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on the claim for VA benefits. 38 U.S.C.A. § 5103(a) (West 2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. The Board finds that VA has satisfied the duty to notify. Specifically, a March 2008 letter provided notice before the initial unfavorable decision in July 2008 regarding what information and evidence was needed to substantiate his claim for increased rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The same letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records, pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records and VA treatment records have been obtained and considered. In June 2011 the Board remanded the claim, directing the RO/AMC to obtain any relevant VA treatment records dated after June 2008. The RO/AMC complied with this directive, obtaining VA treatment records dated July 2008 through June 2011 and associated them with the claims file. The Veteran has not identified any additional outstanding records that VA should seek to obtain on his behalf. The remand also directed that the Veteran be provided with a VA examination to determine the current degree of severity of the Veteran's service-connected left hand disability. Such examination took place in June 2011. The Board finds that the RO/AMC substantially complied with the remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (where there is substantial compliance with the Board's remand instructions a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998)). The Veteran was provided with VA examinations of the left hand in March 2008 and June 2011. The Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected left hand disability as they include interviews with the Veteran, review of the claims file, review of x-rays and EMG testing, and full physical examinations with sensory and range of motion (ROM) testing. The Veteran has not alleged, nor does the record show, that his service-connected left hand disability has worsened in severity since the most recent examination in June 2011. As such, a new examination is not required. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The Board finds that all relevant facts have been properly developed, and all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Increased Rating Claim Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). A. Background The Veteran underwent a peripheral nerves VA examination in March 2008. The Veteran reported that his left hand condition had progressively worsened since his last examination in 2006. Specifically, he had more stiffness, increased difficulty gripping items with the hand on the job, dropping items, increased difficulty doing his job. The Veteran experienced daily sensations of electric shock, pain, pins and needles, burning, numbness, weakness, and heat in all of his left hand. The pain migrated to different parts of the left hand and was intermittent, lasting minutes to seconds and varying from mild to severe. The pain could occur at rest and its triggers were unknown. During flare-ups he self-limited and refrained from using the left hand entirely. The examiner performed reflex testing and reviewed an electromyography (EMG) conducted in September 2007, which showed median neuropathy at the left carpal tunnel area. The examiner diagnosed left hand carpal tunnel syndrome with significant effects on the Veteran's usual occupation; namely decreased manual dexterity, problems with lifting and carrying, weakness or fatigue, and pain. The condition also affected usual daily activities (ADLs), with a mild effect on chores and severe effects on exercise and sports. In conjunction with the peripheral nerves examination, the same 2008 VA examiner also performed a VA hand, thumb, and fingers examination in March 2008. The report reflects the same reported medical history and symptoms. The Veteran reported a usual occupation of burglar alarm technician and he had worked full time in that job for five to ten years. The Veteran was taking Ibuprofen 800mg for pain. He reported that he was right-hand dominant. There had been an overall decrease in left hand strength and dexterity, in addition to pain, limited motion, weakness, stiffness in all digits of the left hand. Daily flare-ups occurred in all digits at the interphalangeal, proximal interphalangeal (PIP), distal interphalangeal (DIP), metacarpal-phalangeal (MCP), and carpal-metacarpal (CMC) joints. The flare-up precipitating factors were uncertain because pain often occurred at rest with no activity. The flare-ups lasted hours and were severe and he avoided using his left hand. On physical examination, all of the digits of the left hand had range of motion within normal limits except for the little finger at the PIP joint. That finger had flexion from 50 to 110 degrees both actively and passively. (It had a persistent flexion.) There was no pain on any active, passive, or repetitive motion in any of the digits. There was no additional loss of motion in any of the digits on repetitive use. The examiner also reviewed x-rays of the left hand taken in September 2006 and August 2007. The 2006 x-ray showed mild degenerative change in all distal interphalangeal joints, moderate degenerative change in the first carpal metacarpal at the first MCP joint, and persistent flexion of the PIP joint of the little finger (possibly due to tendon laceration). The 2007 x-ray showed moderate osteoarthritis involving the first carpal metacarpal (CMC) joint. Based on the foregoing and his peripheral nerves examination, the 2008 VA examiner made the following left hand diagnoses: osteoarthritis of the first CMC joint; degenerative arthritis of all DIP joints; and limited ROM of the little finger at PIP joint secondary to residual of tendon injury. These diagnoses had the same significant effects on the Veteran's usual occupation and ADLs that were described in the peripheral nerves examination report. VA treatment records show that in July 2008 the Veteran was evaluated for left hand pain that had existed for years and a burning sensation. The pain ranged from a 3 out of 10 (3/10) to 10/10 at its most severe. Repetitive motion aggravated the symptoms, and nothing alleviated them. The Veteran was noted as right-hand dominant. He denied redness, swelling, or stiffness. The VA physician diagnosed carpal tunnel syndrome (CTS) and prescribed pain medication, alternating ice and heat, and ROM exercises. The Veteran was not sure if he wanted surgery and deferred that referral. He was seen again in August 2009 for left hand pain and CTS. The Veteran described aching, intermittent, and sharp pain as well as paresthesia. He declined a referral to the Hand Clinic and agreed to monitor symptoms and be referred if they worsened. In September 2009 his pain level was at 3/10 but it was noted that the level could go much higher during a flare-up. He reported being laid off a few weeks prior from his job of nine years because he could not complete his job function installing security systems due to his left hand pain. In September 2010 he reported minor pain, and in December 2010 it was at a 3/10. In his April 2009 notice of disagreement, the Veteran stated that he had claimed the injury as a "left hand injury" because it was not just a particular joint or finger that caused him pain, but the entire hand. The pain was most severe from the beginning of the knuckles of the left hand and shot up toward the forearm. He stated that the use of his hand had become more and more limited over time and provided several examples of his limitations: unable to put together a shed; dropping a pot of pasta while carrying it to the sink because of a shooting pain in the hand; unable to play baseball with his grandson; driving with just his right hand; needing help to tear open a packet of artificial sweetener; unable to dance with his wife using both hands; being awoken by shooting pain in the hand; unable to help carry heavy items when going to the beach; struggling to carry groceries into the house; suddenly dropping an item held by the left hand without warning; and unable to help with household chores. Pain medication provided only brief minimal relief. In his substantive appeal dated June 2010 he stated that difficulty gripping and extreme pain caused him to involuntarily retire in August 2009, earlier than planned. His job required crawling in attics, pulling wires, handling heavy drills, and using tools like screwdrivers. His left hand problems rendered him unable to perform these tasks without endangering himself and others. Recently his hand had begun locking up after holding the telephone. In March 2011 the Veteran had a VA Occupational Therapy Consult for his left hand. The occupational therapist noted that the Veteran is right-hand dominant and that he had experienced left hand pain since it was crushed in service. The Veteran had been assigned a splint but he did not use it often because it added discomfort. Current x-ray showed fixed flexion of the little finger at the PIP joint and moderate degenerative changes in the hand. His therapy goals were to eliminate numbness in the left hand and regain its use. Examination showed paresthesias in the median nerve distribution area of the left hand. The Veteran reported his hand falling asleep while driving, dropping objects, difficulty with forceful or sustained gripping, waking up with paresthesias and pain, and increased discomfort and pain with attempts to increase use of the left hand. His current pain was 3/10 but ranged to 10/10 at its worst. The pain was in the thenar area, volar MP's area of digits, and radiated to the forearm. The occupational therapist assessed decreased functional use of the left hand, pain, CTS symptoms, and decreased strength of the left hand. He was to attend therapy twice a week. At a mental health appointment shortly thereafter, the Veteran reported a pain range of 4/10 to 6/10 and that he was getting physical therapy. The Veteran underwent a second peripheral nerves VA examination in June 2011. The Veteran was retired and not employed. The Veteran reported that his left hand condition had progressively worsened and that he had recurrent severe pain that was aggravated by activities requiring prolonged gripping such as using a broom, drill, or hammer, or carrying a heavy object. He took naproxen but did not use a splint assigned to him by a hand surgeon because it did not help. The Veteran reported peripheral nerves symptoms of stiffness and pain. The examiner performed reflex and sensory testing, finding decreased vibration, pain/pinprick, and light touch in the ring and little fingers. There was neither decreased motor strength nor muscle atrophy in the left hand. The 2011 examiner reviewed the 2006 x-ray, 2007 x-ray, and 2007 EMG. The examiner diagnosed median nerve entrapment neuropathy due to carpal tunnel entrapment. The diagnoses resulted in neuritis, neuralgia, and nerve dysfunction, with effects on the Veteran's ADLs; namely sustained gripping, hammering, sweeping, and drilling. The 2011 examiner stated that the condition represents a moderate disability due to pain generated by sustained gripping with pain as the most disabling symptom. In conjunction with the peripheral nerves examination, the same 2011 VA examiner also performed a hand, thumb, and fingers examination in June 2011. The report reflects the same medical history and symptoms, with the addition of being awoken by intense pain on occasion. The Veteran was taking naproxen for pain twice a week. He reported that he was right-hand dominant. There had been no overall decrease in left hand strength or dexterity, but there was pain and stiffness in all digits of the left hand. On physical examination, ROM of the first and second fingers was normal. The ring finger had objective evidence of pain on active ROM and with repetitive motion, but no limitation of motion. The little finger had objective evidence of pain and limitation of motion on active ROM. With repetitive motion, there was pain but no additional limitation of motion. The thumb had objective evidence of pain on active ROM and with repetitive motion, but no limitation of motion. There was no ankylosis of any digit. There was a deformity of the little finger at the PIP joint, described as a flexion contraction of 20 degrees. Based on the foregoing and his peripheral nerves examination, the 2011 VA examiner diagnosed degenerative arthritis of all digits in the left hand and flexion contraction of the little finger at PIP joint. These diagnoses had moderate effects on the ADLs of chores, exercise, sports, and recreation; as well as mild effects on dressing and grooming. The examiner concluded that this represents a mild degree of disability. B. Sensory Neuropathy Diagnostic Code 8515 relates to impairments of the median nerve and provides that a 10 percent disability evaluation is assigned for mild, incomplete paralysis of the median nerve of the minor or major hand. A 20 percent disability evaluation is warranted for moderate, incomplete paralysis of the minor hand, and a 30 percent disability evaluation is contemplated for moderate, incomplete paralysis of the major hand. A 40 percent disability evaluation is warranted for severe, incomplete paralysis of the minor hand, and a 50 percent disability evaluation is contemplated for severe, incomplete paralysis of the major hand. A 60 percent disability evaluation is contemplated for complete paralysis of the minor hand, and a 70 percent disability evaluation is contemplated for complete paralysis of the major hand. 38 C.F.R. § 4.124a, DC 8515. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. When the involvement is bilateral, the ratings should be combined with application of the bilateral factor. Id. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence in this case consistently shows that the Veteran is right-handed. Therefore, any left hand disability evaluation will correspond with the minor ratings. The service-connected DJD with sensory neuropathy of the left hand is currently rated as 10 percent disabling. As noted, a 20 percent rating is assigned for moderate incomplete paralysis of the median nerve of the non-dominant hand. Throughout the entire appeal, the Veteran's subjective complaints have included chronic pain, numbness, difficulty with sustained gripping, pins and needles, burning, and stiffness in his left hand. At times he has also complained of weakness, locking, and decreased dexterity. His complaints are considered credible, competent, and probative of the nature and severity of his condition. The VA examiner has estimated his median nerve entrapment neuropathy with neuritis, neuralgia, and nerve dysfunction symptoms to be moderate in nature and the Board agrees. The probative evidence does not suggest severe or complete paralysis of the left hand. The objective findings have been fairly consistent throughout the appeal. Accordingly, for the entire appeal period, the Veteran is entitled to an increased rating of 20 percent for sensory neuropathy of the median nerve under DC 8515. C. Other Diagnostic Codes The Board has considered whether it may be appropriate to rate the Veteran's left hand disability under other DCs. In both VA examinations and in VA treatment records, he has consistent diagnoses of arthritis (referred to DJD, osteoarthritis, and degenerative arthritis) that are distinct from the diagnoses related to sensory neuropathy. Specifically, his arthritis-related diagnoses during the appeal period are as follows. The thumb had mild degenerative change at the DIP joint, diagnosed by x-ray in September 2006. The June 2011 examiner found objective evidence of pain on active ROM and with repetitive motion, but no limitation of motion. The first finger had mild degenerative change at the DIP joint and moderate degenerative change of the first carpal metacarpal at the first MCP joint, diagnosed by x-ray in September 2006. Moderate osteoarthritis involving the first CMC joint was confirmed by the 2007 x-ray and the March 2008 VA examiner. At all examinations, there was normal range of motion without pain on active, passive, or repetitive motion, and there was no additional loss of motion on repetitive use. The second finger had mild degenerative change at the DIP joint, diagnosed by x-ray in September 2006. At all examinations, there was normal range of motion without pain on active, passive, or repetitive motion, and there was no additional loss of motion on repetitive use. The ring finger had mild degenerative change at the DIP joint, diagnosed by x-ray in September 2006. In March 2008 there was no pain on any active, passive, or repetitive motion and no additional loss of motion on repetitive use. The June 2011 VA examiner found objective evidence of pain on active ROM and with repetitive motion, but no limitation of motion. The little finger had mild degenerative change at the DIP joint and persistent flexion of the PIP joint which may be due to tendon laceration, diagnosed by x-ray in September 2006. The March 2008 VA examiner found flexion between 50 and 110 degrees both actively and passively secondary to residual of tendon injury. A March 2011 x-ray showed fixed flexion of the little finger at the PIP joint. The June 2011 VA examiner found objective evidence of pain and limitation of motion on active ROM. With repetitive motion, there was pain but no additional limitation of motion. There was a deformity of the little finger at the PIP joint, described as a flexion contraction of 20 degrees. More generally speaking, a March 2011 x-ray showed moderate degenerative changes in the hand. Throughout the appeal period, the Veteran consistently reported subjective symptoms of pain and stiffness in all digits of the left hand. At no point during the appeal period was ankylosis of any digit found. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, supra. The possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45; Mitchell, supra. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The relevant evidence of record, which includes the Veteran's lay statements, VA treatment records, and the March 2008 and June 2011 VA examination reports, show that during the course of the appeal the Veteran's left hand disability has been productive of considerable pain and functional impairment. However, granting a disability rating for functional loss due to pain would result in an impermissible overlapping of symptomatology. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different DCs is to be avoided when rating a Veteran's service-connected disabilities. However, it is possible for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several DCs. 38 C.F.R. § 4.14. The critical element permitting the assignment of multiple ratings under several DCs is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (emphasis added). In this case, while the evidence confirms that the Veteran has experienced the symptom of functional loss due to pain during the appeal period, the Board has already rated that symptom in connection with sensory neuropathy under DC 8515. Accordingly, that symptom cannot overlap with the symptomatic pain from arthritis. Therefore, the Board cannot assign a separate rating for functional loss due to pain from arthritis, as left hand pain is already contemplated within the symptomatology of the disability rating granted under DC 5815. Finally, the schedule for rating disabilities provides for limitation of motion of individual digits in the hand. The only digit which showed limitation of motion during the appeal period was the little finger. Diagnostic Code 5230 addresses limitation of motion of the ring or little finger. For any limitation of motion in either hand, the maximum and only rating available is 0 percent, a noncompensable rating. The little finger had limitation of motion with a flexion contraction of 20 degrees. This limitation of motion is not contemplated under DC 8515; therefore there is no danger of overlapping symptoms. It is a separate and distinct manifestation attributable to the same injury, which would permit a rating under multiple DCs. However, as the rating criteria only provide for a non-compensable evaluation, no benefit would be served by a separate grant. D. Other considerations The Board has also considered whether an extra-schedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The United States Court of Appeals for Veterans Claims (Court) has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. When the analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. However, in this case, the rating criteria reasonably describe the claimant's disability level and symptomatology. The Veteran's sensory neuropathy is characterized by moderate pain, stiffness, numbness, burning, and functional impairment. These manifestations are contemplated in the applicable rating criteria. His DJD is characterized by pain and limitation of motion of the little finger. These manifestations are contemplated in the applicable rating criteria. The Board does not find that the Veteran has described other functional effects that are "exceptional" or not otherwise contemplated by the assigned evaluation. Rather, his description of left hand symptomatology is consistent with the degree of disability addressed by such evaluation. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of an extraschedular rating is not warranted. ORDER An increased schedular rating of 20 percent, but no higher, for sensory neuropathy of the left hand is granted, effective February 14, 2008. REMAND The record shows that the Veteran is not working and the evidence suggests that he may be unemployable due, at least in part, to his service-connected disabilities. Specifically, the Veteran asserts that his left hand symptoms, including weakness, pain, and loss of gripping strength, rendered him unable to continue his work installing security systems and he was laid off. Alternately he has stated that he had to involuntarily retire earlier than planned for the same reason. The 2008 VA examiner noted significant occupational effects from his service-connected disabilities. Moreover, the Veteran is service-connected for depressive disorder secondary to his left hand disability. When evidence of unemployability is submitted during the appeal from an assigned disability rating, a claim for TDIU benefits will be considered part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the Veteran has asserted that he is unemployed due to his service-connected disabilities, and evidence in the claims file suggests he may have been laid off or forced to retire because of occupational limitations related to his service-connected disabilities. The Board notes that it referred this issue to the RO in its June 2011 remand. However, the claims file and electronic paperless file show no evidence that the RO has taken any action with respect to the TDIU claim. Moreover, the Veteran has continued to assert his unemployability due to service-connected disabilities as recently as July 2012. As the TDIU claim has not been considered in the first instance by the RO, it will be remanded for the action set out below. Accordingly, the case is REMANDED for the following action: 1. Issue the Veteran and his representative a notice letter that complies with the requirements of 38 U.S.C.A. § 5103 (a) and 38 C.F.R. § 3.159, concerning the information or evidence needed to establish entitlement to TDIU benefits. 2. Request that the Veteran identify any outstanding VA or private treatment records pertaining to his service-connected disabilities relevant to the TDIU claim. Take appropriate measures to request copies of any outstanding records of pertinent VA or private medical treatment and associate these with the claims file. 3. Notify the Veteran that he may submit statements, including from others, describing the service-connected disabilities' symptoms and impact on his ability or inability to work. 4. After undertaking any additional development deemed appropriate, the RO should adjudicate the TDIU claim. If the benefit sought remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given an opportunity to respond before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs