Citation Nr: 1315077 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 98-18 361 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to a rating in excess of 30 percent for carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy, prior to February 2, 2001. 2. Entitlement to a rating in excess of 50 percent for carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy, effective February 2, 2001. 3. Entitlement to an effective date prior to March 1, 2011, for a grant of a 50 percent rating for service-connected pain disorder, mood disorder associated with carpal tunnel syndrome, right wrist. 4. Entitlement to an effective date prior to March 1, 2011, for a grant of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Stephen J. Wenger, Attorney at Law ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to December 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 1998 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board issued a decision denying this appeal in October 2008. In March 2009, following a Joint Motion for Remand, the United States Court of Appeals for Veterans Claims (Court) remanded the case to the Board. The Board remanded the case to the RO in August 2009 and in April 2011. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The two earlier effective date issues are REMANDED to the RO. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. Prior to February 2, 2001, the Veteran's service-connected carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy was manifested by no more than moderate incomplete paralysis; and is not so exceptional or unusual as to render impractical the application of the regular schedular standards. 2. Effective February 2, 2001, the Veteran's service-connected carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy is not manifested by complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy in 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; pain with trophic disturbances; and is not so exceptional or unusual as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. Prior to February 2, 2001, the criteria for entitlement to a disability evaluation in excess of 30 percent for the Veteran's service-connected carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8515 (2012). 2. Effective February 2, 2001, the criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Under VCAA, codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a), 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify After reviewing the claims file, the Board finds that the claimant has been notified of the applicable laws and regulations which set forth the necessary criteria for the benefits currently sought. In letters sent in June 2001 and October 2005, the claimant was informed of the information and evidence necessary to warrant entitlement to an increased rating for right wrist carpal tunnel syndrome disability. Moreover, in those letters, the appellant was advised of the types of evidence VA would assist her in obtaining as well as her own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). On March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess, 19 Vet. App. at 486. Additionally, this notice must include notification that a disability rating and an effective date for the award of benefits will be assigned if the benefits are awarded. Dingess, 19 Vet. App. at 488. In this case, the letter sent in March 2006 provided the notice contemplated by Dingess. The appellant was provided with notice of the types of evidence necessary to establish a disability rating and an effective date for any rating that may be granted, and this letter explained how VA determines disability ratings and effective dates. This letter complied with the notice requirements for increased rating claims enumerated in Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). As noted, the RO provided the Veteran with notice in June 2001 and October 2005 (Dingess in March 2006), subsequent to the initial adjudication. While the notices were not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The claim was subsequently readjudicated in December 2001, April 2003, April 2006, June 2008, January 2011 and August 2011 supplemental statements of the case, following the provision of notice. The appellant has not alleged any prejudice as a result of the untimely notification, nor has any been shown. The Board notes that while the above notices were sent to the appellant subsequent to the August 1998 rating decision currently on appeal, defects as to the timeliness of the statutory and regulatory notice are rendered moot because the Veteran's claim on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield, 444 F.3d 1328. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of her claim, and is not prejudiced by any technical notice deficiency. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). These facts notwithstanding, the Veteran has not demonstrated any prejudice with regard to the content of the notice. The U.S. Court of Appeals for the Federal Circuit previously held that any error in VCAA notice should be presumed prejudicial, and that VA must bear the burden of proving that such an error did not cause harm. Sanders v. Nicholson, 487 F.3d 881 (2007). However, the U.S. Supreme Court has since reversed that decision, finding it unlawful in light of 38 U.S.C.A. § 7261(b)(2), which provides that, in conducting review of decision of the Board, a court shall take due account of rule of prejudicial error. The Supreme Court in essence held that except for cases in which VA has failed to meet the first requirement of 38 C.F.R. § 3.159(b) by not informing the claimant of the information and evidence necessary to substantiate the claim, the burden of proving harmful error must rest with the party raising the issue, the Federal Circuit's presumption of prejudicial error imposed an unreasonable evidentiary burden upon VA and encouraged abuse of the judicial process, and determinations on the issue of harmless error should be made on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record as it stands includes sufficient competent evidence. All available pertinent VA treatment records have been obtained. The Board has reviewed the Veteran's Virtual VA electronic claims file and find no evidence pertinent to the claim on appeal that is not already a part of the paper claims file. Pursuant to the Board's August 2009 remand, the RO referred this case to the Director of Compensation and Pension Service (Director) for the purpose of determining whether assignment of an extraschedular rating is warranted. A February 2010 advisory opinion from the Director is associated with the claims file. The Veteran has been afforded VA examinations focused upon the claim on appeal in April 1998, December 1998, March 2001, July 2007, March 2008, and July 2011. The Board finds that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent features of the Veteran's right wrist carpal tunnel syndrome disability to allow for fully informed application of the appropriate rating criteria in this case. The VA examination reports, in addition to other pertinent probative evidence of record, provide probative medical evidence adequately addressing the issues decided below. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant as relevant to this appeal. Under these circumstances, no further action is necessary to assist the claimant with this appeal. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Legal Criteria, Factual Background and Analysis At the outset, the Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and in Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The present appeal involves the Veteran's claim that the severity of her service-connected carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy warrants a higher disability rating. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 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 evaluation 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. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's service-connected carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy has been rated by the RO under the provisions of Diagnostic Code 8515. Under this regulatory provision, a 30 percent rating is warranted for moderate incomplete paralysis. A 50 percent rating is warranted for severe incomplete paralysis. A maximum rating of 70 percent is warranted for complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy in 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; pain with trophic disturbances. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less that the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. In the present case, it should also be noted that 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 weakened movement, excess fatigability and incoordination. In exceptional cases where the Rating Schedule is deemed inadequate, the Director of Compensation and Pension Service, upon field station submission, is authorized to approve an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1). The Board is precluded from granting an increased rating on an extraschedular basis in the first instance. Floyd v. Brown, 9 Vet. App. 88, 95 (1996). However, it may determine whether a claim merits submission for an extraschedular evaluation, and once that occurs may proceed to address the extraschedular claim on its merits as part of the appeals process. Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the Rating Schedule to determine whether the disability picture is adequately contemplated by the Rating Schedule. If the disability is not adequately contemplated by the Rating Schedule, the second step is to determine whether the Veteran's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If any of these factors are found to exist, the third step is to refer the case to the Director of the Compensation and Pension Service for a determination whether, in order to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Prior to February 2, 2001 The Veteran's claim for an increased rating was received on February 28, 1998. The Veteran was afforded a VA examination in April 1998. At the examination, the Veteran stated that she was working full time. She also stated that she seeks treatment in the VA neurology clinic. She reported that she is taking Neurontin (two tabs, three times per day); but it is not helping much. She also reported using a splint. Upon examination, her right hand showed decreased sensory on the first three fingers. Grasp, motor were decreased compared to the left hand. There was no joint swelling or atrophy. The right wrist had full range of motion; but with pain. X-rays of the right wrist showed small ossific density, soft tissues, volar to distal radius. The Veteran was diagnosed with carpal tunnel syndrome of the right wrist. In May 1998, the Veteran was diagnosed with retained foreign body in the right wrist forearm area; and neuroma of the radial nerve right forearm. She underwent surgery involving exploration of the right forearm wrist; repair of 4.5 cm. wound; and neurolysis and exploration of radial nerve of forearm. The Veteran underwent another VA examination in December 1998. She complained of symptoms of reflex sympathetic dystrophy. These symptoms included severe, burning pains on the right wrist and hand with numbness and paresthesia of the right wrist and hand. She also noted color changes (red) to the surgical site. She stated that she uses a TENS unit and physical therapy. She had also taken Percocet. A neurologic examination revealed dysesthesia, painful to touch on the right wrist and forearm. There was positive Tinel's sign of the right wrist and median nerve. There was decreased pinprick and light touch in the right median nerve distribution on the right hand. In January 2001, the Veteran underwent surgery to remove a foreign body from her right forearm. The foreign body consisted of a shard of glass that had been imbedded in her arm since 1990. In order to warrant a rating in excess of 30 percent, the Veteran's carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy must be manifested by severe incomplete paralysis. The Board finds that the preponderance of the evidence is against such a finding. In April 1998, an examination of the Veteran's right hand showed decreased sensory on the first three fingers; and her ability to grasp was decreased compared to the left hand. However, there was no indication that either her symptoms were so severe as to amount to severe incomplete paralysis. To the contrary, her right wrist had full range of motion (albeit with pain). Likewise in December 1998, the Veteran complained of severe pain. A neurologic examination revealed dysesthesia, painful to touch on the right wrist and forearm; positive Tinel's sign; and decreased pinprick and light touch in the right median nerve distribution on the right hand. However, there was no indication of severe incomplete paralysis. As shown above, the record reflects that the Veteran's symptoms during this period include pain, decreased sensation, and decreased grasping ability of the right hand. There was no evidence of more significant symptoms such as atrophy, muscle wasting, weakness, fatigue, tremor and the like. The Board finds that these "wholly sensory" symptoms, alone, do not constitute evidence which is sufficient to characterize the Veteran's right wrist carpal tunnel syndrome as "severe" warranting a 50 percent disability rating under Diagnostic Code 8515 for the period prior to February 2, 2001. 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. In regards to DeLuca criteria, while the Veteran showed decreased sensory on the first three fingers of her right hand and decreased grasp on the right compared to the left, there was no joint swelling or atrophy. She had full range of motion of the right wrist (albeit with pain). There is no medical evidence to show that there is any additional loss of motion due to pain or flare-ups of pain, supported by objective findings, or due to excess fatigability, weakness or incoordination, to a degree that supports a rating in excess of 30 percent. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a schedular rating in excess of 30 percent prior to February 2, 2001, for carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Effective February 2, 2001 An outpatient treatment report dated February 2, 2001 (one week after surgery to remove a foreign body from her arm) shows that the Veteran complained of much difficulty using her right hand. She stated that it had plagued her ability to hold employment. It also hampered her in her artistic pursuit as a painter. She stated that she had to train herself to learn how to paint left handed. Upon examination, the Veteran held her right hand in a clawed position and tried to avoid any use. The skin in the hands was somewhat atrophic, as were the muscles of the right hand and forearm. The painfulness of the hand and arm precluded formal strength, sensory, and reflex testing. She was assessed with reflex sympathetic dystrophy. The examiner stated that the disorder was longstanding and had not responded to treatment. The prognosis was poor. The Veteran underwent a VA examination in March 2001. The examiner stated that he reviewed the Veteran's claims file in conjunction with the examination. The Veteran complained of pain in the hand, and loss of sensation in the fingers. She stated that she could not use the hand; and that she frequently dropped things. She used her left hand to write. She stated that she is unemployed, and had not worked since 1981 (although the Board notes that at her April 1998 examination, she stated that she was working full time). She stated that she was involved in a motor vehicle accident in 1999, which resulted in a piece of glass being imbedded in her right lower forearm on the radial aspect. Upon examination, the right hand and arm were held in antalgic fashion. There was mild atrophy of the abductor pollucis brevis (APB). Strength in the shoulder and elbow was essentially normal, except that there was give-way strength loss due to pain. Strength of hand muscles was difficult to touch due to painful skin. However, strength of the APB was essentially normal. She could do opposition of the thumb to little finger. Flexion of the distal thumb phalanx was essentially normal with give-way weakness due to painful skin. Flexion of the index finger and middle finger metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints were essentially normal, with give-way weakness due to painful skin. Extension of the MCP, PIP, and DIP joints was normal. There were mild trophic skin changes in the right hand affecting the dorsal and ventral aspect. There was loss of sensation to pinprick in the right index finger. There was hyperesthesia and hyperpathia in the right lower forearm, in the ventral aspect from just below the elbow down into the hand, and in the dorsal aspect from approximately halfway down the lower forearm. There was no sensory loss in the radial or in the ulnar nerve distribution. She was diagnosed with reflex sympathetic dystrophy. The examiner stated that the Veteran is not employable; but that she remains independent for activities of daily living. There was no clear loss of strength in the median nerve innervated muscle; however, complete assessment of strength was limited due to painful skin. The Veteran underwent a neurologic examination in June 2007. The examiner reviewed the claims file in conjunction with the examination. The Veteran complained of almost constant right hand pain and numbness. The pain ranged from a 5 to an 8 on a scale of 1-10. She reported having difficulty working and performing activities of daily living due to pain. She described the pain as shooting up her right forearm to the right shoulder. She also described an on and off again burning sensation and severe electric shock-like feeling in her right hand, arm, and shoulder. She reported wearing a brace and taking Neurontin, ibuprofen, oxycodone, Tylenol, and tramadol. She stated that the pain was worse at night and caused difficulty sleeping; and that she stopped working in the 1980s and was currently unemployed. Upon examination, strength of the right shoulder and right arm were slightly limited due to pain. Right hand grip was 3/5. Right hand opponens pollicis was 3/5. Right thumb flexor pollicis brevis and abductor brevis was 4/5. There was atrophy noted of the thenar muscle of the right hand. Deep tendon reflexes were 2+ symmetrical in the upper extremities, biceps, and brachioradialis. Triceps were 1+ symmetrical. There was decreased pinprick and light touch sensation noted on median nerve distribution of the right hand. There was hyperesthesia and hyperalgesia noted on the sensory examination of the right hand, and to some extent on the right forearm area. The examiner stated that the Veteran's condition was moderately severe in nature and that the pain and numbness in her right hand will affect (to some extent) her physical and sedentary employment status. The Veteran underwent a VA orthopedic examination in July 2007. The claims file was reviewed in conjunction with the examination. The Veteran complained of constant, sharp, burning pain that averaged an 8-9 on a scale of 1-10. She stated that the pain is aggravated by motion. She also complained that her skin over the right wrist was sensitive to touch. The examiner noted that she is right hand dominant. She reported that she was independent in the activities of daily living. She uses a wrist splint, as well as pressure gloves. She reported additional limitations following repetitive use and during flare-ups. She did not report any incapacitating episodes during the past 12 months. Upon examination, the Veteran's right wrist showed no gross deformity or edema. There was no significant skin discoloration; however, she did have severe allodynia over the wrist, hand, and forearm. Skin temperature appeared to be within normal limits. There was no skin dystrophic change. Right wrist range of motion revealed dorsiflexion from 0 to 45 degrees with pain throughout range of motion; palmar flexion from 0 to 30 degrees with pain at the end of range of motion; radial deviation from 0 to 25 degrees, and ulnar deviation from 0 to 20 degrees all associated with pain at the end of range of motion. Following five repetitive range of motion, the pain and range of motion remained the same. There was no evidence of fatigue, weakness, or lack of endurance. Sensation was mildly impaired to light touch over fingertips. She was diagnosed with complex regional pain syndrome in the right forearm, wrist, and hand; and status post carpal tunnel release and ganglion cyst removal. The July 2007 examiner reexamined the Veteran in March 2008. The Veteran reported that the pain in her right upper extremity had not changed. Upon examination, there was swelling in the right hand associated with chronic skin discoloration. There was severe allodynia in the right hand. Right wrist range of motion revealed dorsiflexion from 0-30 degrees; palmar flexion from 0-30 degrees; ulnar deviation from 0-15 degrees, and radial deviation 0-15 degrees associated with pain throughout range of motion. Following five repetitive wrist range of motion, the pain was increased; but range of motion remained the same. There was no evidence of fatigue, weakness, or lack of endurance. Examination of the right thumb revealed range of motion from 0-45 degrees associated with pain throughout range of motion. MCP joint showed 0-30 degrees associated with pain throughout range of motion. Following five repetitive range of motion at these joints, pain and range of motion remained the same. There was no evidence of fatigue, weakness, or lack of endurance. The Veteran was able to flex her thumb; but she was not able to perform thumb opposition or abduction due to pain. Range of motion of the second through fifth fingers at DIP joints revealed 0-45 degrees of motion associated with pain throughout the motion. At PIP joints, range of motion was 0-50 degrees associated with pain throughout range of motion. The examiner was not able to examine range of motion of MCP joints of the second through fifth finger due to severe pain. The Veteran was able to flex all fingers. The examiner stated that "There is no evidence of complete paralysis of right median nerve. The Veteran is able to perform pronation of the right forearm despite severe pain." Pursuant to the August 2009 Board remand, the RO referred this case to the Director of Compensation and Pension Service for the purpose of determining whether the assignment of an extraschedular rating was warranted for the Veteran's right wrist carpal tunnel syndrome disability. The Director found that the Veteran's service-connected right carpal tunnel syndrome was moderately severe; and despite stellar ganglion blocks, splints, pressure gloves, antineuropathic pain medications and opiates, she had chronic, regional pain syndrome. The Director concluded that entitlement to an extra-schedular evaluation in excess of 30 percent prior to February 2, 2001, and in excess of 50 percent effective February 2, 2001, for the service-connected right carpal tunnel syndrome was not warranted. On July 2011 VA peripheral nerves examination, the Veteran reported that she had been diagnosed with right carpal tunnel syndrome in the 1980's and underwent right carpal tunnel release surgery in 1983. She had two surgeries and also had an injury on the right forearm in 1990 and a glass piece injury. She now has constant pain and numbness of the right hand. She reported that she had been dropping objects and cannot drive a car or do household chores because of continued right wrist and right hand pain, dysesthesia, and burning sensation. The pain level is anywhere from 5/10 to 8/10. The pain on the right hand travels and shoots up to the right forearm and to the right forearm to the right shoulder, and she gets a burning sensation and severe electric shock-like feelings intermittently on the right hand and right wrist. Neurological examination revealed decreased motor strength on the right shoulder due to pain. The right hand grip was 3/5; and right opponens pollicis was 3/5. The right thumb flexor pollicis brevis was 4/5. There was moderate atrophy noted on the right thenar muscle. Reflexes were 2+ symmetrical on biceps and brachioradialis. Triceps were 1+ symmetrical. There was decreased pinprick and light touch sensation noted in median nerve distribution of the right hand. There were areas of hyperesthesia noted. Also, sensory examination revealed dysesthesia of the right forearm and right wrist. The diagnoses were carpal tunnel syndrome of the right hand, reflex sympathetic dystrophy (RSD), and status post right hand carpal tunnel release surgery. The examiner noted that the Veteran's current carpal tunnel syndrome is moderate to severe. She has constant pain and dysesthesia and difficulty using the right hand because of continued pain, numbness, weakness, and intermittent of RSD will affect to some extent both physical and sedentary employment status. He noted further that the disability is moderate to severe and progressive in nature. She was on multiple pain medications. In order to warrant a rating in excess of 50 percent, the Veteran's carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy must be manifested by complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy in 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; pain with trophic disturbances. The Board finds that the preponderance of the evidence is against a finding of complete paralysis. The March 2001 examiner concluded that there was no clear loss of strength in the median nerve innervated muscle. The June 2007 examiner concluded that the Veteran's condition was moderately severe in nature, and observed that right hand grip strength was 3/5. The July 2007 examiner found that the Veteran had right wrist range of motion consisting of dorsiflexion from 0 to 45 degrees; palmar flexion from 0 to 30 degrees; radial deviation from 0 to 25 degrees; and ulnar deviation from 0 to 20 degrees. Following five repetitive range of motion, the pain and range of motion remained the same; and there was no evidence of fatigue, weakness, or lack of endurance. Sensation was mildly impaired to light touch over fingertips. She was examined by the July 2007 examiner again in March 2008, and he found that the Veteran could achieve right wrist range of motion consisting of dorsiflexion from 0-30 degrees; palmar flexion from 0-30 degrees; ulnar deviation from 0-15 degrees, and radial deviation 0-15 degrees. Again, following five repetitive wrist range of motion, the pain was increased; but range of motion remained the same; and there was no evidence of fatigue, weakness, or lack of endurance. Examination of the right thumb revealed range of motion from 0-45 degrees. MCP joint showed 0-30 degrees. The Veteran was able to flex her thumb; though she was not able to perform thumb opposition or abduction due to pain. Range of motion of the second through fifth fingers at DIP joints revealed 0-45 degrees of motion. At PIP joints, range of motion was 0-50 degrees. The examiner stated that "There is no evidence of complete paralysis of right median nerve. The Veteran is able to perform pronation of the right forearm despite severe pain." The July 2011 examiner noted that the Veteran's currently diagnosed carpal tunnel syndrome of the right hand, reflex sympathetic dystrophy and status post right hand carpal tunnel release surgery disability is moderate to severe and progressive in nature. On neurological examination the right hand grip and right opponens pollicis were 3/5, and the right thumb flexor pollicis brevis was 4/5. There was moderate atrophy of the right thenar muscle. Reflexes were 2+ symmetrical on biceps and brachioradialis, and triceps were 1+ symmetrical. She had decreased pinprick and light touch sensation with median nerve distribution of the right hand. There were areas of hyperesthesia noted. Also, sensory examination revealed dysesthesia of the right forearm and right wrist. The examiner further noted that the Veteran had constant pain, dysesthesia and difficulty using the right hand because of continued pain, numbness, weakness, and intermittent reflex sympathetic dystrophy will affect to some extent both physical and sedentary employment status. As shown here, complete paralysis is not shown and an increased rating to 70 percent is not warranted. Finally, the Board has considered whether additional compensation is warranted under the DeLuca for functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. The Board notes that, the July 2007 (and March 2008 addendum) VA examiner repeatedly stated that repetitive motion did not cause additional limitation of motion; and that there was no evidence of fatigue, weakness, or lack of endurance. Although the July 2011 examiner noted that the Veteran had constant pain, dysesthesia and difficulty using the right hand because of continued pain, numbness, and weakness, her reported limitation of motion is still insufficient to justify a higher rating. The Board therefore concludes that a higher rating based on DeLuca factors is insufficient to justify a higher rating. Thus, the Board concludes that a higher rating based on those factors is not warranted. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a rating in excess of 50 percent effective February 2, 2001 for carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Extraschedular Consideration Pursuant to August 2009 Board remand, the issues were referred to the Director of VA Compensation and Pension Service for consideration of entitlement to an extra-schedular evaluation (under 38 C.F.R. § 3.321(b)(1).. In February 2010 the Director determined that an extra-schedular evaluation was not warranted based on the evidence of record. Although the Director found that extraschedular evaluation was not warranted, the Board's interpretation of the determination is that the current ratings for the right carpal tunnel syndrome adequately contemplate the carpal tunnel syndrome symptoms. The Director noted that the main feature complained of by the Veteran was pain. It was then noted that the Veteran is already receiving a separate rating for a pain disorder associated with the carpal tunnel syndrome. The Director suggested that consideration be given to a higher rating for the pain syndrome. The RO did in fact assign an increased rating of 50 percent for the pain disorder by rating decision in August 2011. In other words, the purpose behind an extraschedular rating has been effectively served in this case by the fact that the Veteran is receiving a separate rating for the pain associated with the carpal tunnel syndrome. To assign an extraschedular rating for the pain symptomatology under the provisions of Code 8515 for the carpal tunnel syndrome would be essentially be compensating the Veteran twice for the same symptom (pain). See 38 C.F.R. § 4.14. After careful consideration of the record, the Board finds that an extra-schedular rating is not warranted under the circumstances of this case. ORDER Entitlement to a rating in excess of 30 percent for carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy, prior to February 2, 2001 is not warranted. Entitlement to a rating in excess of 50 percent for carpal tunnel syndrome, right wrist with reflex sympathetic dystrophy, effective February 2, 2001 is not warranted. REMAND By rating decision in August 2011, the RO increased the rating for the service-connected pain disorder, mood disorder associated with carpal tunnel syndrome, right wrist to 50 percent, effective from March 1, 2011. The RO also granted entitlement t TDIU, also effective from March 1, 2011. The record includes a notice of disagreement received in September 2011 in which the Veteran's attorney specifically with the assigned effective dates. He argues that an effective date of December 18, 2008, is warranted. It does not appear that a statement of the case has been issued in response to the September 2011 notice of disagreement. The proper course of action is to remand the matter to the RO. Manlincon v. West, 12, Vet.App. 238 (1999). Accordingly, the effective date issues are hereby REMANDED to the RO for the following actions: The RO should take appropriate action, including issuance of a statement of the case, on the appeals initiated by the veteran from the August 2011 rating decision which assigned an effective date of March 1, 2011 for the 50 percent rating for pain disorder, mood disorder and for the grant of TDIU. The veteran and his representative should be clearly advised of the need to file a timely substantive appeal if the veteran wishes to complete an appeal from that determination. The purpose of this remand is to comply with the holding of the Court in Manlincon v. West, 12, Vet.App. 238 (1999). ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs