Citation Nr: 1315714 Decision Date: 05/13/13 Archive Date: 05/15/13 DOCKET NO. 08-32 139 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to a separate disability evaluation for a neurological disorder, to include ulnar neuropathy, associated with the service-connected left elbow or left shoulder disabilities. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from June 2000 to September 2006. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office in Denver, Colorado (RO) which, in pertinent part, granted service connection for left shoulder reconstruction (rated 10 percent disabling), and for residuals of a left elbow fracture (rated noncompensable). The Veteran appealed for higher ratings. The Veteran testified at a June 2011 Travel Board hearing before the undersigned Veterans Law Judge (VLJ). The hearing transcript has been associated with the claims file. In September 2011 and November 2012, the Board remanded this case for further development. In its November 2012 decision and remand, the Board granted a higher 20 percent rating for the service-connected left shoulder disability, effective from January 6, 2012, denied entitlement to a higher rating for the service-connected left elbow disability, found that the appeals for higher ratings for the Veteran's service-connected left shoulder and elbow disabilities raised the issue of whether a separate rating is warranted for any associated neurological abnormalities, and remanded that issue for further development. As noted in the Board's prior remands, the issues of entitlement to service connection for degeneration in the sesamoid bones of the bilateral feet and entitlement to a compensable evaluation for service-connected left shoulder scars have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over these issues and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The weight of the competent and probative evidence of record shows that during the rating period prior to January 4, 2012, the Veteran had ulnar neuropathy due to his service-connected residuals of a left elbow fracture, that was manifested by no more than mild impairment in the ulnar nerve distribution. 2. During the rating period from January 4, 2012, the weight of the competent and probative evidence of record shows that the Veteran does not have current chronic neurological symptomatology of the left upper extremity that is associated with his service-connected left elbow or left shoulder disabilities. CONCLUSIONS OF LAW 1. During the rating period prior to January 4, 2012, the criteria are met for a separate 10 percent rating, but no higher, for left ulnar neuropathy associated with the service-connected residuals of a left elbow fracture. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.14, 4.120, 4.124a, Diagnostic Code 8516 (2012); Esteban v. Brown, 6 Vet. App. 259 (1994); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). 2. During the rating period from January 4, 2012, the criteria are not met for an additional separate compensable rating for a claimed chronic neurological disorder associated with the service-connected left elbow or shoulder disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.14, 4.120, 4.124a, Diagnostic Codes 8516, 8616, 8716 (2012); Esteban, supra; Fenderson, supra. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, an October 2006 letter was sent to the Veteran regarding his initial service connection claims, prior to the July 2007 rating decision on appeal. In cases such as this, where service connection has been granted and initial disability ratings and effective dates have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008). Neither the appellant nor his representative has advanced any such arguments. The provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case (SOC) if the disagreement is not resolved. And this has been done; the Veteran has received both an SOC and supplemental statements of the case, most recently in February 2013, discussing the downstream disability rating element of his claim, citing the applicable statutes and regulations, and discussing the reasons and bases for assigning the initial ratings for his service-connected left shoulder disability, left elbow disability, and left wrist carpal tunnel syndrome. Moreover, additional notice was sent in a July 2008 letter. Thus, based on the record as a whole, the Board finds that a reasonable person would have understood from the information that VA provided to the appellant what was necessary to substantiate his claim, and as such, that he had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication was not affected. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Here, the appellant's private and VA medical treatment records and private medical records have been associated with the claims file. The appellant was afforded VA medical examinations in November 2006, August 2008, and January 2012. A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). These examinations were conducted by medical professionals, and the associated reports reflect review of the appellant's prior medical history. The examinations included a report of the symptoms for the left upper extremity and demonstrated objective evaluations. The examiners were able to assess and record the clinical status of the appellant's service-connected disabilities of the left shoulder, elbow, and wrist. Physical examination was accomplished. Pursuant to the Board's remand in November 2012, additional medical comment was obtained in November 2012 from the January 2012 VA examiner regarding the Veteran's claimed additional neurological disability of the left upper extremity. The Board finds that the examination reports were each sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. In addition, it is not shown that the examinations were in any way incorrectly conducted. Further, the VA examination reports addressed the applicable rating criteria. Additional medical comment was obtained in November 2012. As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). The Board concludes that the appellant was afforded adequate physical examinations, and the November 2012 medical opinion provides a complete rationale as to whether there is a separate neurological disability related to the service-connected left shoulder and elbow disabilities, with review of the medical evidence and reconciling of the medical findings throughout the appeal. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A Court or Board remand confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, VA treatment records were obtained for the appellant on remand. The RO also arranged for a VA medical examination and additional medical comment as directed by the Board's remands. Therefore, substantial compliance has been achieved. All relevant facts with respect to the higher (separate) rating claim addressed in the decision below have been properly developed. Under the circumstances of this case, a remand would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). VA has complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. The Board also notes that it is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. However, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the 2011 Board hearing. Law and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Governing law provides that the evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14 (2012). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. See 38 C.F.R. § 4.124a and specific nerve involved for diagnostic code number and rating. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, or typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code and rating. 38 C.F.R. § 4.124. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of lost or impaired function substantially less that the type pictured 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. See note at "diseases of the peripheral nerves" in 38 C.F.R. § 4.124a. As to ulnar nerve impairment, a 10 percent rating is warranted for mild incomplete paralysis of the minor upper extremity. A 20 percent rating is warranted for moderate incomplete paralysis. A 30 percent rating requires severe incomplete paralysis. A 50 percent rating requires complete paralysis with "griffin claw" deformity due to flexor contraction of the ring and little fingers, very marked atrophy in the dorsal interspaces and the thenar and hypothenar eminences, loss of extension of the ring and little fingers, an inability to spread (or reverse) the fingers, an inability to adduct the thumb, and weakness of flexion of the wrist. 38 C.F.R. § 4.124a, Diagnostic Code 8516. These provisions apply to neuritis of the ulnar nerve (Code 8616) and neuralgia of the ulnar nerve (Code 8716). Analysis This case arises from an appeal of the initial grant of service connection and assignment of disability ratings for the service-connected left shoulder and left elbow disabilities. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals his initial rating, VA must consider whether to "stage" the rating to compensate him for times since the effective date of his award when his disability may have been more severe than at others). During the pendency of this appeal, in its November 2012 decision and remand, the Board granted a higher 20 percent rating for a service-connected left shoulder disability, effective from January 6, 2012, and denied entitlement to a higher rating for service-connected residuals of left elbow fracture. The Board also found that the Veteran's appeal for higher ratings for his service-connected left shoulder and elbow disabilities raised the issue of whether a separate rating is warranted for any associated neurological abnormalities. See Esteban, supra (holding that evaluations for distinct disabilities resulting from the same injury can be combined so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition). The Board notes that the Veteran currently has three service-connected disabilities of the left upper extremity: left shoulder reconstruction (currently rated 20 percent disabling under Diagnostic Codes 5024-5201), residuals of left elbow fracture (rated noncompensable under Diagnostic Code 5206), and left wrist carpal tunnel syndrome (CTS) with ganglion cyst (rated 10 percent disabling). Service connection has also been established for right wrist CTS (rated 10 percent disabling). His bilateral CTS has been evaluated under Diagnostic Code 8515, which pertains to paralysis of the median nerve. The Veteran contends that a higher rating should be assigned for his service-connected left elbow disability because he has ulnar nerve damage of the left elbow. He reported limited arm strength and pain on motion. See Notice of Disagreement, received in December 2007. According to the January 2012 VA examination report and the Veteran's testimony at the June 2011 Board hearing, his left arm is his minor extremity. Records on file reflect that the Veteran injured his left shoulder and elbow during service, including a fracture of the left elbow when he fell from a bicycle. He underwent two surgeries on the left shoulder during service, and one afterward. A November 2006 VA examination report reflects that the Veteran reported elbow symptoms including sharp pain with some movements or with lifting more than twenty pounds. He estimated that his left elbow pain was present 60 percent of the time. With regard to its affect on his occupation, the Veteran stated that it was hard for him to do certain actions, especially rotational movements. With regard to its affect on activities of daily living, the Veteran stated that he had to give up his hobby of restoring vehicles. On examination, there was no tenderness to palpation of the left elbow. Range of motion of the left elbow was from 0 to 130 degrees, and after repetitive exercise was 0 to 135 degrees. There was no observed manifestation of pain during range of motion testing. No additional limits to range of motion could objectively be attributed during a flare-up. The VA examiner noted that a December 2005 electromyography (EMG) study that was performed during active service showed minimal entrapment of the median nerve at or near the wrist, primarily sensory. There was no evidence of denervation or motor involvement, and was consistent with bilateral early CTS. On examination, the hand musculature was approximately the same bilaterally, and grip strength was full. Tinel's and Phalen's tests were negative. The Veteran was accurate for sharp, dull discrimination both laterally and medially of all digits of both hands. The examiner diagnosed the Veteran with a healed fracture to the radial head of the left elbow, and bilateral CTS. The Veteran has reported tingling and numbness of the upper extremities, and he has been diagnosed with bilateral CTS. A November 2007 VA occupational therapy note reflects that the Veteran complained of numbness in the ulnar distribution. The diagnostic assessment was possible bilateral cubital tunnel [syndrome]. A November 2007 VA orthopedic progress note states that the Veteran had symptoms that involved paresthesias in the ulnar nerve distribution which seemed more likely related to the service-connected radial head fracture and elbow injury. A March 2008 VA treatment record reflects that the Veteran had numbness and tingling coming and going in his bilateral upper extremities, and that the use of elbow braces helped to decrease these symptoms. An April 2008 VA neurosurgery note reflects that the Veteran complained of neck and left arm pain, and occasional numbness in the left arm. The examiner recommended an EMG to determine if there was nerve root irritation of the cervical spine. An April 2008 EMG was abnormal and showed electrodiagnostic evidence of mild, primarily demyelinating left ulnar neuropathy across the elbow without signs of denervation on EMG. There was no definite electrodiagnostic evidence of left upper extremity radiculopathy or myopathy. A May 2008 VA treatment record reflects that the Veteran experienced anterior shoulder pain with burning and weakness of the medial arm and hand if he raised his arm to shoulder height. He stated that he was frequently dropping objects at work and at home. He stated that he could not hold his arm out for more than several seconds without pain. On examination, there was pain on palpation of the medial condyle of the left elbow with shooting pain to the left forearm/hand. Tinel's test was negative. In a July 2008 statement, the Veteran wrote that he had pain throughout the range of motion of the left elbow as well as weakness of the elbow, and that he used a sleeping brace. At an August 2008 VA examination, the Veteran stated that he wore a sleeping brace to keep his left elbow from bending while he slept. He reported experiencing pain over the medial aspect of the left elbow when pressure was applied to this area, and the pain extended a few inches above and a few inches below the elbow. He stated that his range of motion was "ok." However, he felt his left elbow was a little weaker when lifting objects. With regard to its effects on his work, he stated that he had to reposition his left arm and elbow as needed when doing flexing activities of the left elbow, which slowed down his work. With regard to his daily activities, he had to limit his hobby of restoring vehicles, and had to interrupt yard and home maintenance work periodically. On examination, the Veteran's left elbow showed no redness, swelling, or effusion. There was some tenderness when the ulnar groove of the left elbow was percussed in the medial elbow area. The musculature of the left upper extremity was symmetrical and normal. The examiner could not discern any weakness on strength testing. There was no atrophy and no fasciculations of the muscles. On neurological examination, there was normal 10 gram monofilament touch sensation and pinprick from dull discrimination in all the fingers of the left hand and in the forearm. With regard to range of motion, the left elbow had flexion from 0 to 136 degrees (the examination report uses the word "extension" but it is clear that the examiner must have meant flexion in light of the range reported, as shown in Plate I of section 4.71a and Diagnostic Codes 5206 and 5207), 90 degrees of pronation, and 90 degrees of supination. There was no observed manifestation of pain with range of motion testing and no additional limitation after repetitive motion. The pertinent diagnoses were left shoulder reconstruction with chronic daily occurring pain, and left elbow fracture. A September 2008 orthopedic history and physical performed to evaluate the left shoulder shows that the Veteran complained of numbness, tingling and pain down his arm in the medial elbow area and the hand. Both the ulnar and radial sides of his hand were having numbness and tingling, worse in the ulnar distribution. EMG studies showed slowing of the ulnar nerve at the elbow. On examination, sensation was intact to light touch, motor strength was grossly normal, and no neurological deficit was seen. In his October 2008 substantive appeal, the Veteran stated that he never regained full strength or stability in his left elbow after his fracture, and he had a lot of "nerve issues" extending from the area. He said that doctors told him he had ulnar nerve damage that probably resulted from the fracture and hemorrhage in the elbow. Private medical records reflect that the Veteran underwent surgery of the left shoulder in December 2008. VA medical records show that in February 2010, the Veteran was seen for bilateral wrist complaints. The examiner noted that the Veteran had vague symptoms with numbness and tingling and his description of median versus ulnar neuropathy were inconsistent with a normal distribution pattern. Tinel's sign at the wrists were equivocal, and there was a slight positive Tinel's sign at the left elbow. The diagnostic assessment was bilateral wrist pain, possible ganglion cyst. At the June 2011 Board hearing, the Veteran stated that when he had to pick something up at work he felt a severe weakness in the elbow, as if it were going to break. He testified that he had pain and tenderness in the left elbow. He stated that when he pressed on his "funny bone", he could feel it down his forearm and halfway up his bicep. He also reported decreased grip strength in his left hand. He said his fine motor skills in that hand seemed fine. The Board remanded this case in September 2011 for a VA examination to assess the severity of the Veteran's left elbow and shoulder disabilities and also to identify any neurological damage associated with the left elbow disability. At the January 2012 VA examination, the Veteran described pain and abnormal sensations from his left elbow down to his little finger. He denied having flare-ups which impacted the functioning of his elbow or forearm. On examination, there was localized tenderness or pain on palpation of the elbow. With regard to ranges of motion, flexion of the left elbow was to 145 degrees or greater, which was normal according to the examination report. There was no objective evidence of painful motion. There was no limitation in extension of the elbow and no objective evidence of any painful motion. There was no additional limitation after repetitive testing. His left elbow strength was found to be normal in both flexion and extension. The examiner found that the Veteran had no functional loss or impairment of the left elbow or forearm, and that it did not impact his ability to work. A January 4, 2012 EMG showed no electrodiagnostic evidence of a left ulnar neuropathy. There was no slowing or conduction block across the elbow. There has been improvement since the prior EMG from April 2008, which showed mild focal slowing across the elbow. There was no electrodiagnostic evidence of a left carpal tunnel syndrome, and no electrodiagnostic evidence of an acute, subacute or chronic left cervical radiculopathy. The examiner indicated that the Veteran had a left radial head fracture in April 2005, and the fracture had healed. The examiner stated that the Veteran had full range of motion of the elbow, including supination and pronation. With this injury he developed neuropathy involving the ulnar nerve. The April 2008 EMG/NCS showed some slowing of nerve conduction, but a recent EMG/NCS showed normal function of the nerve. Although the Veteran had complaints of abnormal sensations in his left upper extremity, there was currently no objective evidence to support this. The diagnoses were radial head fracture, healed and resolved, and ulnar neuropathy, resolved. In November 2012, the Board found that given the findings in the January 2012 VA examination report, the evidence of record was not sufficient to determine whether the diagnosis of ulnar neuropathy in April 2008 was distinct from the Veteran's CTS or represented additional disability not yet compensated. The case was remanded for an addendum medical opinion. In a November 2012 VA addendum medical opinion, the examiner who conducted the January 2012 VA examination stated that based on the normal results of the most recent EMG/NCS it is not at least as likely as not that the Veteran has any neurological impairment associated with his left elbow and/or left shoulder disabilities. In view of the most recent EMG/NCS in January 2012, it is not at least as likely as not that the Veteran has neurological impairment associated with his left elbow and/or left shoulder disabilities distinct from his CTS. The rationale for the opinion was as follows: there are three main nerves in the distal upper extremity: the ulnar nerve, the median nerve and the radial nerve. CTS is a condition in which the median nerve is entrapped or compressed at the level of the wrist. The symptoms are typically pain at the wrist with numbness and weakness in the hand. Injuries of the elbow that include nerve problems are commonly associated with the ulnar nerve. The common term for this condition is cubital tunnel syndrome. After an injury, nerves may have decreased function and over time that function may improve as the injury resolves. When a nerve is compressed, the function is commonly compromised. After treatment (medical or surgical), the compression is released and the nerve will likely improve its function. EMG and nerve conduction studies (NCS) measure the viability and function of the peripheral nerves. The most recent EMG/NCS in January 2012 was read as normal. Specifically, there was no evidence of compromise of the left ulnar nerve or median nerve. Any injury or disability involving these two nerves had resolved. There were no signs of CTS or cubital tunnel syndrome. This EMG/NCS also assessed the function of the nerves as they travel proximally to the neck. These nerves traverse the shoulder. The EMG/NCS showed no compromise in this region as well. The April 2008 EMG/NCS showed mild impairment of the left ulnar nerve. As the median nerve is the nerve that is involved with CTS, impairment of the ulnar nerve is not associated with CTS. The Board finds that the November 2012 VA medical opinion is adequate and highly probative, as it is based on a thorough rationale, a physical examination conducted by the same examiner in January 2012, and a January 2012 EMG study. Governing case law provides that VA compensation may only be awarded to an applicant who has disability existing on the date of application, not for past disability. See Degmetich v. Brown, 104 F.3d 1328 (1997); see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Upon review of all of the competent and probative evidence of record, and for the reasons and bases discussed below, the Board finds that a separate, staged, compensable rating is warranted for mild left ulnar neuropathy during the period prior to the normal January 4, 2012 EMG. As noted, a November 2007 VA orthopedic progress note indicated that the Veteran's paresthesia symptoms in the ulnar nerve distribution seemed more likely related to the service-connected radial head fracture and elbow injury, and an April 2008 EMG was abnormal and showed electrodiagnostic evidence of mild, primarily demyelinating left ulnar neuropathy across the elbow without signs of denervation on EMG. On examination in September 2008, sensation in the left upper extremity was intact to light touch, motor strength was grossly normal, and no neurological deficit was seen. During the period prior to January 4, 2012, since the ulnar nerve involvement was wholly sensory, the Board finds that no more than mild incomplete paralysis of the ulnar nerve was shown during this period. See note at "diseases of the peripheral nerves" in 38 C.F.R. § 4.124a. The Board finds that the neurological impairment from the Veteran's residuals of the left elbow fracture (minor upper extremity) is equivalent to mild incomplete paralysis of the ulnar nerve, supporting a separate rating of 10 percent under Diagnostic Code 8516 during this period. An even higher rating of 20 percent under Diagnostic Code 8516 is not indicated, since moderate incomplete paralysis of the left ulnar nerve is not demonstrated during the period prior to January 4, 2012, and there was no demonstrated motor impairment or other symptoms consistent with moderate impairment of the ulnar nerve. In this regard, the Board notes that the Veteran is already service-connected for left CTS, with neurological impairment due to median nerve impairment, and such impairment (such as reduced grip) may not be rated again under the rating criteria pertaining to the ulnar nerve, as that would constitute pyramiding. See 38 C.F.R. § 4.14. However, during the period since January 4, 2012, the competent and probative evidence clearly shows that the Veteran's transient ulnar nerve symptoms associated with his service-connected left elbow disability have resolved, including by EMG study. Thus, after a review of all of the evidence of record, the Board finds that during the rating period from January 4, 2012, the weight of the objective evidence of record does not show that the Veteran has current chronic neurological symptomatology associated with his service-connected left elbow or shoulder disabilities. Thus, since January 4, 2012, the claimant is not entitled to an additional separate compensable rating for any claimed adverse neurological symptomatology associated with his service-connected left elbow and shoulder disabilities during the rating period on appeal. 38 C.F.R. §§ 4.120, 4.124a, Diagnostic Codes 8516, 8616, 8716; Esteban, supra. Therefore, the Board finds that the preponderance of the evidence warrants a separate, 10 percent rating for mild left ulnar neuropathy during the period prior to January 4, 2012, but is against entitlement to a separate rating for a chronic neurological disorder, to include ulnar neuropathy, claimed as associated with the service-connected left elbow or left shoulder disabilities, during the period from January 4, 2012. Staged ratings have been assigned. See Fenderson, supra. ORDER During the period prior to January 4, 2012, entitlement to a separate 10 percent rating for left ulnar neuropathy associated with the service-connected residuals of a left elbow fracture, is granted, subject to the laws and regulations governing the payment of monetary benefits. During the period from January 4, 2012, entitlement to a separate rating for a neurological disorder, to include ulnar neuropathy, claimed as associated with the service-connected left elbow or left shoulder disabilities, is denied. ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs