Citation Nr: 1317727 Decision Date: 05/31/13 Archive Date: 06/06/13 DOCKET NO. 09-40 462 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for service-connected carpal tunnel syndrome (CTS) of the right wrist. 2. Entitlement to a compensable disability rating for service-connected residuals of a fracture of the left 4th metatarsal. 3. Entitlement to an initial compensable disability rating for a service-connected scar, associated with CTS of the right wrist. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and E.W. ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The Veteran served on active duty from September 1970 to September 1973 and from April 1975 to November 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts, and a December 2011 rating decision by the RO in Roanoke, Virginia. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in March 2013. A transcript of the hearing is included in the Veteran's electronic records in Virtual VA. The Board notes that the Veteran was denied an increased rating for her service-connected hearing loss at the time of the rating decision of November 2007. She submitted a notice of disagreement (NOD) with the denial in July 2008. She was issued a statement of the case, that included the hearing loss issue along with the CTS and 4th metatarsal issues on appeal, in August 2009. The Veteran, through her attorney representative at the time, submitted her substantive appeal in September 2009. She checked the block on the VA Form 9 to show that she was limiting her appeal to three issues - increased ratings for right CTS and the left 4th metatarsal as well as entitlement to a total disability evaluation based on individual unemployability (TDIU) rating. A written statement was included that addressed only the three named issues. See Evans v. Shinseki, 25 Vet. App. 7, 15 (2011) (appellant checked the block on his Form 9 to indicate he was appealing all issues on the SOC but added comments for specific issues; it was error for the Board to consider unlisted issues as not on appeal). Thus, unlike the veteran in the Evans case, this Veteran has knowingly elected to not appeal her hearing loss issue as evidenced by the actions and comments on the Form 9 and statement submitted by her attorney. The Board also notes that the Veteran's then attorney representative submitted a statement in March 2010 that indicated the RO had failed to adjudicate the issue of an increased rating for bilateral hearing loss based on evidence submitted on November 2, 2009. The Board has reviewed the named evidence and has found no reference to hearing loss. The evidence related to surgery on the Veteran's right wrist for service-connected CTS. Thus, no issue was raised to evaluate the Veteran's hearing loss disability at that time and the appeal period for the prior adjudication had expired in October 2009 (60 days after the SOC was issued). During the course of the current appeal, the Veteran was seeking entitlement to a TDIU rating as well as an increased rating for service-connected residuals of a fracture of the left ankle. She was granted an increased rating of 10 percent for the left ankle disability by way of a rating decision dated in January 2010. The effective date assigned for the increased rating was June 2, 2009. The Veteran submitted her NOD with the effective date of the rating in March 2010. She maintained that the effective date should be as of September 22, 2006. The Veteran was granted entitlement to a TDIU rating in October 2011. The effective date for the grant of benefits was from June 2, 2009, to June 19, 2009, with a temporary total 100 percent rating from June 19, 2009, to August 1, 2009, and then a TDIU rating from August 1, 2009. A separate rating decision in December 2011 granted eligibility for Dependents Education Assistance (DEA) benefits, effective from June 2, 2009. The Veteran submitted an NOD with the effective date for the TDIU rating and DEA eligibility in February 2012. She stated that both benefits should be effective from September 22, 2006. The RO issued a rating decision in August 2012. The rating decision established an effective date of September 22, 2006, for the Veteran's TDIU rating, DEA eligibility, and 10 percent rating for her left ankle disability. Notice of the rating action was provided that same month. There is no indication that the Veteran has expressed disagreement with any aspect of the rating action at this time. As noted, the Veteran served on active duty until November 1988 during her second period of military service. She submitted a claim for service connection for several issues in December 1988. The Veteran was granted service connection for a number of issues in August 1989. The issues included right hallux valgus, CTS of the right wrist, both of these disabilities received a 10 percent rating. Additional disabilities included status post bunionectomy with left hallux valgus, hypertension, residuals of fracture of the left 4th metatarsal, residuals of a fracture of the left ankle and residuals of a whiplash injury of the cervical and dorsal spine. The latter disabilities all received a noncompensable disability rating. The effective date for the grant of service connection was established as of November 20, 1988, the day after the Veteran's discharge from service. The Veteran was granted an increased rating, to 20 percent for her service-connected cervical sprain disability in October 1996. The effective date for the increase was May 30, 1996. An increased rating for the issue was denied in March 1999. A review of the rating history for the disability in March 1999 now only listed a 20 percent rating as of May 30, 1996. There was no reference to the effective date for original service connection of November 20, 1988. The Veteran's disability rating for CTS of the right wrist was increased to 30 percent in December 1999. The effective date of the increase was as of June 8, 1999. The rating decision included the history of the disability ratings for the disability with the 10 percent rating from November 20, 1988, and the new 30 percent rating from June 8, 1999. The Boston RO adjudicated several additional issues and provided a rating decision in January 2001. The Veteran's disability rating for right hallux valgus was increased to 20 percent effective from July 14, 2000. Service connection for two other issues was denied. A review of the "Subject to Compensation" portion of the January 2001 rating decision reveals that the RO changed the effective date for the disability rating for all of the Veteran's service-connected disabilities to June 8, 1999, with the exception of the 20 percent rating just granted for right hallux valgus. The prior 10 percent rating was listed as effective from June 8, 1999, and the increase of 20 percent from July 14, 2000. The Veteran had been granted service connection for several additional disabilities after the initial rating in August 1989 and had an increased rating for her hypertension in the intervening years. However, even the effective date for those disabilities was changed to June 8, 1999. The Board is unable to discern the basis for why the change in the effective date for the service-connected disabilities was made. The unexplained change affects the status of the Veteran's service-connected disabilities in several ways. First, the rating for those disabilities granted as of November 20, 1988, are protected after 20 years. See 38 U.S.C.A. § 110 (West 2002); 38 C.F.R. § 3.950 (2012). In addition, those disabilities where service connection has been in effect for 10 years or more are protected. 38 U.S.C.A. § 1159 (West 2002); 38 C.F.R. § 3.957 (2012). The listing of a possibly incorrect effective date for service connection or increased ratings could affect the Veteran in both ways. On remand, the RO must review the Veteran's disability ratings to ensure the appropriate effective dates for service connection and any increase in ratings are reflected for the Veteran unless there is a justifiable basis identified for a change in the dates. Finally, the Veteran submitted a claim for an increased rating for her CTS of the right wrist that was received in July 1999. At the time she reported CTS in both hands. No claim for service connection for the CTS of the left hand was adjudicated. The Veteran's attorney representative submitted a statement in September 2012 that cited to the submission of June 1999 [sic] as a claim for service connection for CTS of the left hand that had not yet been adjudicated. The Veteran also raised this issue at the time of her hearing in March 2013. The issue has not yet been adjudicated by the agency of original jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and the issue is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Throughout the rating period on appeal, except for the period from June 19, 2009, to August 1, 2009, the Veteran's right (major) CTS has been manifested by no more than moderate incomplete paralysis of the median nerve. The Veteran received a temporary 100 percent rating during the above period due to surgery. 2. The service-connected fracture of the left 4th metatarsal is manifested by subjective pain and slight tenderness with normal ranges of motion and normal gait. The evidence of record does not establish that the Veteran has a moderate foot disability involving residuals of a fracture of the left 4th metatarsal. 3. The Veteran's surgical scar, associated with surgery for her right wrist CTS, is located in the palm of the right hand, measured as 4.2-centimeters by 0.1-cm., is superficial and is not painful on objective examination. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for service-connected CTS of the right wrist, except for the period from June 19, 2009, to August 1, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2012). 2. The criteria for an initial compensable disability rating for residuals of service-connected fracture of the left 4th metatarsal are not met. 38 U.S.C.A. §§ 1155; 5107;38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5284 (2012). 3. The criteria for a compensable rating for service-connected scar, associated with CTS of the right wrist, have not been met. 38 U.S.C.A. §§ 1155; 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.118, Diagnostic Codes 7800-7805 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. Notice should also explain how VA assigns effective dates for benefits. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The Veteran submitted her claim for increased ratings for her right CTS and left 4th metatarsal disabilities in September 2006. The RO wrote to the Veteran in March 2007. She was provided with notice on how to substantiate her claim for increased ratings. She was further advised of the information required from her to enable VA to obtain evidence on her behalf, the assistance that VA would provide to obtain evidence for her, and that she should submit such evidence or provide VA with the information necessary for VA to obtain such evidence on her behalf. She was asked to submit any medical evidence that she had. She was also afforded the notice required in Dingess. The RO again wrote to the Veteran in August 2008. She was provided with additional notice on how to substantiate her claim. Information was provided as to how her right CTS disability was rated to include the diagnostic code and disability ratings for her disability. The Veteran was granted service connection for a scar associated with surgery for her CTS of the right wrist in December 2011. Where, as here the claim is for a higher initial disability rating, the claim for service connection is substantiated. No additional VCAA notice is required with respect to the downstream issue of the disability rating assigned to the now service-connected disability. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Especially, when the claimant has made no argument for a specific rating or effective date with the initiation of the claim. In regard to the Veteran's right CTS and left 4th metatarsal the Veteran has not disputed the contents of the VCAA notice in this case. She was afforded a meaningful opportunity to participate in the development of her claim. She was provided the necessary information on how to substantiate her claim for increased ratings and given examples of the types of evidence that would be beneficial in that endeavor. She identified or submitted evidence in support of her claim, to include evidence of her surgery for her right CTS in 2009 and records of podiatry care at different times during the pendency of her appeal. Thus, the Board is satisfied that the duty to notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. The Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate her claim. All available evidence pertaining to the Veteran's claim has been obtained. Her service treatment records (STRs) were already of record. VA records were also identified by the RO and obtained. Records from the Social Security Administration (SSA) were also obtained. The Veteran submitted VA treatment records and private records in support of her claim. The Veteran also testified at a Travel Board hearing in March 2013. At the hearing the Veterans Law Judge identified the issues on appeal. The requirement to show that the service-connected disabilities met the criteria for increased/higher ratings was discussed. The Veteran presented testimony and argument as to how her symptoms satisfied the criteria for increased/higher ratings. The Board finds that the Veterans Law Judge provided the Veteran with a discussion of the issues on appeal, the evidence necessary to establish increased or higher ratings and the evidence of record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103(c) (2012). The Veteran was afforded examinations in July 2007 and October 2011. The Board finds that the examinations were adequate to allow proper adjudication of the issues on appeal. The examiners conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disabilities. The Board also notes that another set of examinations which was scheduled for September 2012 but did not take place (possibly due to a misdirected notice letter) pertained to other disabilities than those which are currently on appeal to the Board. Therefore, that situation does not present a basis for scheduling additional examinations for the appealed disabilities. The Board finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). I. Background The Veteran served on active duty from September 1970 to September 1973 and from April 1975 to November 1988. She submitted her claim for VA disability compensation in December 1988. The Veteran's STRs showed that she had suffered a fractured left ankle whole playing softball in July 1972. She also fractured the base of the 4th metatarsal of the left foot in August 1983. She was treated with a short leg walking cast at the time. The Veteran had a bunionectomy of the left great toe in November 1985. A neurology consult from November 1987 attributed the Veteran's complaint of pain in her left foot as a residual of the bunionectomy. The Veteran was also diagnosed with CTS in service. The Veteran was afforded a VA examination in June 1989. The Veteran's prior fracture of the left 4th metatarsal was noted but no residuals were identified. X-rays of the left foot did not show any evidence of the prior fracture, only findings related to the bunionectomy of the left great toe. Electromyography (EMG) and nerve conduction studies (NCS) confirmed CTS. The Veteran was granted service connection for CTS of the right wrist and for residuals of a fracture of the left 4th metatarsal in August 1989. The CTS was rated as 10 percent disabling and the 4th metatarsal received a noncompensable disability rating. As noted in the Introduction, the Veteran was also granted service connection for status post bunionectomy with hallux valgus on the left and residuals of a fractured left ankle. The Veteran sought entitlement to service connection for several disabilities over the next ten years. There was no evidence regarding problems with her left 4th metatarsal. The Veteran was evaluated for complaints involving both hands at Burbank Hospital and was diagnosed with bilateral CTS beginning in 1993. In June 1999 the Veteran submitted a claim for service connection for several issues. In July 1999 she submitted a claim for increased ratings for several disabilities to include her CTS of the right wrist. The Veteran was afforded a VA examination in November 1999. The Veteran complained of numbness in the tips of her fingers and thumb and sometimes in the dorsum of the palm of her hand. She also sometimes experienced aching and would occasionally drop small objects without it being immediately apparent. The examiner noted the prior evaluation and treatment for CTS at Burbank Hospital. On physical examination the Veteran did not have any thenar or hypothenar atrophy visible. The examiner said there was no other atrophy of the muscles of the right hand or fingers visible. He said the Veteran's strength was normal and symmetrical. The Veteran was said to have absent sensation to touch dorsally and ventrally and over the dorsal and ventral surfaces of the fingers and thumb in a glove-like fashion. The assessment was CTS of the right hand, confirmed by testing in 1995 and with non-specific findings on current examination. The Veteran's disability rating for her CTS of the right wrist was increased to 30 percent in December 1999. The effective date for the increase was June 8, 1999. VA records for the period from August 2005 to January 2006 were associated with the claims folder. The records documented treatment for a number of issues but not her right CTS or left 4th metatarsal disabilities. The Veteran was seen for complaints of pain originating in her back and radiating down her legs. She has had complaints of knee pain. The Veteran was denied a compensable rating for her service-connected left 4th metatarsal disability in January 2006. The Veteran submitted a claim that was received on September 22, 2006. She said she wanted to increase her disability rating for, inter alia, her right CTS disability. She also said she had been unable to work due to problems with her back and hands. Additional VA treatment records for the period from January 2006 to February 2007 were obtained. A treatment entry from February 2006 noted that the Veteran complained of numbness and weakness in both hands. She said she had started to drop things from her hands in the last month. She attributed this to a worsening of her CTS. She also said she had tingling and numbness in the tips of the fingers on both hands. The Veteran was noted to have a diagnosis of diabetes mellitus. The assessment was tingling and numbness of the hands and dropping thing likely due to CTS versus diabetes mellitus neuropathy. A neurology consult and testing was ordered to evaluate for possible surgical intervention. The Veteran was seen for a neurology consult on March 24, 2006. The Veteran said she had been dropping things from her hands for the past year. She felt the symptoms were equal in both hands but was right-handed so this affected her more. She said that when the numbness was severe it was also painful. She denied radiation of the numbness to her hands and wrists. She reported her symptoms were worse after doing household chores. The assessment was that the Veteran had symptoms suggestive of symptomatic CTS but no persuasive findings were found on neurologic examination. The examiner said there was evidence of mild peripheral neuropathy which she said was most likely related to suboptimally treated diabetes. The Veteran was to have testing to assess the possible etiology of her symptoms. The Veteran was prescribed splints for both wrists in July 2006. The Veteran had a podiatry consult in March 2006. The main purpose was to conduct a diabetic foot examination. The examiner noted that the Veteran was service-connected for several foot injury residuals. No problems regarding the left 4th metatarsal were raised by the Veteran or noted on examination. The Veteran underwent EMG and nerve conduction velocity (NCV) testing in August 2006. The results showed moderate right carpal tunnel entrapment, a severe left carpal tunnel entrapment and a severe left ulnar neuropathy at the elbow on the left side. The report also said there was electrical evidence of mild peripheral neuropathy of the upper extremities. An October 2006 primary clinic visit noted the Veteran continued to have bilateral hand numbness with the left worse than the right. A lump in her right wrist was noted, starting about two months earlier. The Veteran was seen for an orthopedic surgery consult in November 2006. Pertinent diagnoses included left ulnar entrapment at the elbow, left CTS, right CTS and right wrist volar ganglion cyst. Her index and middle fingers were symptomatic on her right hand as opposed to all the fingers on the left hand. The Veteran was noted to have increased numbness with percussion of the carpal tunnel of the right extremity. The ganglion cyst was also noted. Surgical options for the left wrist problems were discussed. The entry said the right CTS was not severe enough at this time to warrant decompression. The Veteran had surgery to address the problems associated with her ulnar and median nerve problems on the left in December 2006. An orthopedic surgery clinic note from January 2007 noted the Veteran complained of right wrist volar ganglion with carpal tunnel-type symptoms. The Veteran related she had intermittent symptoms in her right thumb, index and long finger. She also had a right volar mass. A magnetic resonance imaging (MRI) had been planned to evaluate the mass but had not been done. On physical examination no limitations of the right wrist were noted. The plan was to obtain a MRI study of the mass to determine if it affected the Veteran's CTS. The Veteran was afforded a VA examination in July 2007. The Veteran continued to complain of right hand numbness in the index and long finger. In regard to the left 4th metatarsal, the Veteran gave a history of a fracture in service. She said she experienced pain in her left foot from time to time but it was very hard to tell where the pain was coming from other than the lateral aspect of her foot. The Veteran's left ankle and bilateral bunionectomy disabilities were also noted. The Veteran complained of pain in her foot, particularly her big toes if she stood for any period of time. On physical examination the examiner said there was slight planus with some degree of firm, soft tissue swelling on the dorsum of the left foot. There was no indication of specific pain in the area of the fourth metatarsal. In regard to the right arm, the examiner said there was extension of the right elbow to almost 0 degrees with further flexion to 130 degrees. The forearm showed supination to 85 degrees and pronation to 75 degrees. There was positive Phalen's testing at the carpal tunnel but not at the cubital tunnel. There was dysesthesias and tingling of the right hand upon dorsiflexion and volar flexion, particularly in the index and long fingers. The motor and sensory examination was within normal limits. The assessment was residuals of left base of the 4th metatarsal fracture and right CTS. The examiner further commented that although no one of the Veteran's impairments, to also include arthritis of the left ankle, bunionectomies, arthritis of the cervical spine, arthritis of the lumbar spine and left carpal tunnel and cubital tunnel syndrome, prevented her from working, the combination of upper and lower extremity problems, plus her cervical and lumbar spine problems would make it very difficult for her to work at any gainful type of employment. The Board notes that the Veteran is not service-connected for a lumbar spine disability or for her left carpal and cubital tunnel disabilities. The Veteran was also afforded a VA general medical examination in July 2007. The examination assessed several other disabilities and did not provide findings in regard to the Veteran's right CTS or left 4th metatarsal disabilities. The Veteran was denied increased ratings for her right CTS and left 4th metatarsal disabilities in November 2007. The Veteran's NOD with the rating was received in July 2008; however, no specific assertions or arguments were made in regard to the disability ratings. The Veteran did submit a medical report from P. V. Ledesma, D.P.M., dated in November 2006. The general assessment was for ankle and foot pain. The Veteran said she had pain in both ankles and the medial aspect of both feet. On examination, Dr. Ledesma said the Veteran had bilateral hammer toes of the second toes. He said that test and x-rays showed mild arthritic changes in the feet at the 2nd MC (metatarso-cuneiform) joint and NC (navico-cuneiform) joint. Prior surgery to the hallux was also noted. A previous Lis Franc dislocation of the foot was identified. The Veteran submitted copies of VA treatment records in January 2009. The records, dated in October and November 2007, respectively, included podiatry clinic entries and orthopedic assessment of the ganglion cyst on the right wrist. The podiatry entries noted the Veteran's problems with her left ankle and bilateral bunionectomies. The examiner said the problem focused area of the left foot revealed pain in the midsection of the midtarsal joint upon range of motion. There was some tenderness but no concrete sharp pain at the dorsum or plantar areas of the metatarsals or their joints. He said the joints ranged freely with normal motion. The examiner said x-rays showed generalized osteoarthritis, especially at the midtarsal joint and Lisfranc's joint areas - the NC joint especially. The Veteran also submitted a copy of a favorable disability decision from the Social Security Administration (SSA) that was dated in October 1996. The Veteran's SSA records were obtained and comprise an entire volume of her claims folder (Volume 4). The records show the Veteran was awarded SSA disability benefits in November 1996, with a disability date of March 1995. The only disability listed at that time was anxiety related disorders. The decision itself noted that the Veteran reported she could not work because of pain and numbness in her back, left shoulder and hands, with CTS in both hands. The decision noted that the Veteran had a severe back impairment, bilateral CTS and severe depression. Although the Veteran did not have an impairment or combination of impairments that met the requirements for disability. The administrative law judge determined that the Veteran's pain and depression precluded her from engaging in substantial gainful work activity. The Veteran underwent a review of her disability status in 2002. A June 2002 determination continued her disability with disorders of the back (discogenic and degenerative) and obesity listed as the primary and secondary disability, respectively. The Veteran perfected her appeal for the issues of increased ratings for her right CTS and left 4th metatarsal disabilities in September 2009. She reported at that time that she had had surgery for her right CTS but the records were not yet available. The Veteran submitted records from D. Ekstrom, M.D., in November 2009. The records covered a period from May 2009 to August 2009 and related to treatment and surgery in regard to the Veteran's right CTS. The Veteran had an initial assessment in May 2009 with a diagnosis of bilateral CTS with the right greater than the left at the time. Included in the records was a letter from Dr. Ekstrom to a Dr. Russell that related the results of the Veteran's status in June 2009. The Veteran was noted to complain of numbness and pain in both hands and wrists. She also reported dropping objects and swelling, mostly in the right thumb and in the fingers of the radial side of the hand. She also reported awakening at night with numbness and tingling. Dr. Ekstrom said the Veteran's distal radio-ulnar joint motion was full and flexion/extension at the wrist was satisfactory. There was pain with manipulation of all five fingers of the right hand. A scar from cyst removal was noted and said to be well healed. She said the Veteran's grip strength was satisfactory and muscle bulk was intact. The impression was bilateral CTS with the right greater than the left. There was ulnar nerve irritation at the cubital tunnel, right greater than the left. She also said there was degenerative joint disease (DJD) of the right thumb and stenosing tenosynovitis of all five digits of both hands. The Veteran had surgery on her right hand and wrist on June 19, 2009. The operative report indicates she had a right carpal tunnel release, steroid injection of the tendon sheaths, 1 through 5 of the right hand and a steroid injection of the right carpometacarpal joint. The Veteran underwent a QTC examination to assess her left ankle disability in December 2009. The examiner noted the Veteran's complaints of ankle and foot pain. The Veteran's bunionectomy scars were noted. The Veteran was noted to walk with a normal gait. There were no findings relative to the left 4th metatarsal. The Veteran provided notice of her relocation to Virginia and a change in her name in June 2010. Her claims folder was transferred from Boston to Roanoke. The RO issued a rating decision that provided a temporary 100 percent rating in August 2011. The temporary total rating, for the Veteran's right CTS surgery, was from June 19, 2009, to August 1, 2009, with the 30 percent rating in effect from that date. VA treatment records for the period from August 2010 to September 2011 were associated with the claims folder. The records include a letter, dated in August 2010; the letter informed the Veteran of the results of x-rays of feet. The x-ray report noted likely postsurgical changes in the bilateral first metatarsal heads and bilateral second through fifth hammertoes deformities. The records included a podiatry clinic entry from October 2010. The examiner noted the Veteran had diabetes and had had foot surgeries over 20 years earlier. She had digital deformities and corns and calluses and pain in the ball of the left foot and numbness in her toes. The examiner said the Veteran was wearing inappropriate shoes for her foot problems. He said there was a palpable neuroma on the left 3rd toe and multi-digital contractures/hammertoes. The assessment included lesions from shoe pressure and friction, diabetes with neuropathy and Morton's neuroma. The Veteran was afforded a QTC examination in October 2011. In regard to the left 4th metatarsal the Veteran gave a history of injury in 1972 while playing softball [the Veteran actually fractured her left ankle at that time, her left 4th metatarsal was fractured in 1983]. She said she had constant pain in the toe that traveled to her foot. She described the pain as burning, aching, and sharp and as a 10/10. The pain was exacerbated by physical activity such as standing or walking. It was relieved by rest. She reported that she had no weakness, swelling or fatigue at rest but had pain, weakness and swelling with standing or walking. She said she was not receiving any treatment for the condition. In regard to her right CTS the Veteran reported tingling and numbness of the fingers with a severity of 4. She said she had no weakness of the fingers. The symptoms occurred constantly. She reported having surgery in June 2000 [sic]. The examiner described the Veteran's surgical scar from the right CTS surgery. The scar was located in the right palm and was linear. The scar measured 4.2-cm by 0.1-cm. The scar was not painful on examination. There was no skin breakdown. The scar was described as superficial with no underlying tissue damage. There was no inflammation, edema, or keloid formation. The examiner said the scar was not disfiguring and did not limit the Veteran's motion. She stated there was no limitation of function due to the scar. The examiner noted that the Veteran was right hand dominant. The examiner said the Veteran's posture was within normal limits as well as her gait. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern. The Veteran did not require any assistive device for ambulation. Her condition did not cause generalized muscle weakness, generalized muscle wasting or any muscle atrophy. The examiner noted the Veteran had a normal range of motion of the right wrist with measurements of the motion provided. See 38 C.F.R. § 4.71, Plate I (2012). There was no limit of joint function by pain, fatigue, wakens, lack of endurance or incoordination after repetitive use. No pain on motion was noted. The examiner also said there was no evidence of a decrease in strength in regard to pulling, pushing and twisting. The examiner further stated that there was no decrease in dexterity as measured by twisting, probing, writing, touching and expression. There was no deformity of any of the digits of the hand. The examiner provided findings on the function of the fingers of the right hand. She said there was no gap between the thumb pad and the right index fingertip and no objective evidence of thumb pain on this attempt or after three repetitions. There was no new or additional limitation of the thumb on repetitive motion. After repetitive use, the motion of the right thumb to the right index finger was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. The examiner also provided regarding dexterity between the thumb and the other fingers of the right hand with no gap between the thumb pad and the other fingers. Further, the examiner said there was no objective evidence of pain with the attempts or additional limitation after three attempts or evidence of pain, fatigue, weakness, and lack of endurance or incoordination. The examiner also reported that the Veteran had a normal range of motion for the proximal interphalangeal (PIP), metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints for all of the fingers on the right hand. See Note (1) for Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, 38 C.F.R. § 4.71a (2012). In addition, the examiner said there was no objective evidence of pain, even after three repetitions and no additional limitation due to pain, fatigue, weakness, lack of endurance or incoordination. The examiner said that examination of the left foot revealed no tenderness, painful motion, weakness, edema, heat, redness, instability, atrophy or disturbed circulation. Palpation of the plantar surface of the left foot revealed no tenderness. Alignment of the Achilles tendon was normal on the left while the Veteran was weight bearing and non-weight bearing. The Veteran did not have any limitation with standing and walking. In regard to a neurological examination the examiner said the motor function was normal for the right upper extremity. The sensory exam to pinprick/pain, touch, position, vibration and temperature was intact on the right. The right upper extremity reflexes were said to be 2+. She said that examination of the right hand showed the Tinel's sign as absent and the Phalen's test as negative. There was no peripheral nerve involvement evident during examination. The examiner also said that non-weight bearing x-ray results of the left foot were abnormal; the results showed prior bunion surgery with minimal DJD in the medial mid-foot. The examiner said that for the VA established diagnosis of fracture of the 4th metatarsal of the left foot the diagnosis was changed to status post fracture of the 4th metatarsal of the left foot. She said there was no evidence of active fracture. The subjective factors to support the change were history given and the objective factors were: Negative exam and DJD in mid foot was medial and not lateral as would be expected for a fracture in the fourth (lateral) metatarsal. For the VA established diagnosis of CTS of the right wrist, the diagnosis was changed to status post CTS surgery, right wrist with scare. The examiner said this was a result of a progression of the previous diagnosis. The examiner stated that there were no residuals of the fracture of the 4th metatarsal of the left foot found on examination. The examiner further stated that the Veteran's conditions did not affect her usual occupation or daily activities. The Veteran was granted service connection for the scar associated with her right CTS surgery in December 2011. She was awarded a noncompensable disability rating from the date of surgery of June 19, 2009. The Veteran submitted records from Colonial Foot Care for the period from November 2011 to December 2011. There was no reference to the left 4th metatarsal. The records included an examination report that focused on the Veteran's left ankle and prior bunionectomies. The Veteran, through her attorney representative, submitted a NOD in February 2012. Pertinent to this appeal was the Veteran's disagreement with the noncompensable rating for her now service-connected scar. The Veteran argued that there was pain from the surgical site itself and that a 10 percent rating was warranted for a painful scar. The Veteran also maintained that her right CTS warranted a 50 percent rating as she continued to have pain and could hardly grasp or hold anything. The Board notes that the Veteran submitted a claim wherein she was seeking increased ratings for several disabilities, to include both bunionectomy disabilities and left ankle disability, as well as service connection for diabetes mellitus in June 2012. The RO wrote to her to provide notice of how to substantiate her claim in August 2012. Records were obtained from Warwick Podiatry for the period February 2012 to June 2012. The Veteran was seen as a new patient in February 2012. She complained of problems with both feet with a history of bunion surgery. The records did not contain any evidence relating to the Veteran's left 4th metatarsal. The Veteran was scheduled for QTC examinations in conjunction with her claim of June 2012. Evidence of record shows that she failed to report for the examinations in September 2012. Additional VA electronic records in Virtual VA, for the period from June 2011 to October 2012, do not reflect treatment for any of the three issues on appeal. The Veteran was noted for her CTS surgical history. The records reflect treatment for a right knee injury in November 2009. She was seen in the emergency room for left knee pain in June 2012. A September 2012 entry noted the Veteran reported having had knee surgery at a non-VA facility. A second entry in September 2012 reported the surgery as left knee replacement surgery. The records also reflect multiple treatment entries for bilateral shoulder pain to include steroid injections. The Veteran and E.W. testified at a Travel Board hearing in March 2013. The Veteran testified regarding her right CTS surgery in 2009. She said she had a scar in the palm of her right hand. In discussing her rating the Veteran said her hand was painful and that she had difficulty in holding things and picking things up with her hands. She said the problem was at the base of her thumbs. The Veteran was asked if it was the scar itself that bothered her and she said "yes" but described generalized problems with her hand and her ability to grasp items and having pain in her hand. The Veteran's representative noted that the Veteran was to be examined in September 2012 and said they thought it would be for two if not all three issues on appeal. There was a discussion on the record as to whether the examination was for the current appeal. The Veteran's witness, E.W., testified as to the Veteran's difficulty in driving a car and going far from her house since her knee surgery. He also said the Veteran had problems with holding the steering wheel of a car. He expressed his concerns with the Veteran's driving, particularly in snow as was present at the time of the hearing. He was concerned that the Veteran was not able to use her left foot. E.W. also expressed concern for the Veteran being able to hold pots and pans while cooking as she had pain and weakness in both hands. In regard to the left fourth metatarsal the Veteran testified about her bunionectomy. She said the toe next to her big toe had rolled on top of it. The Veteran described problems with her left ankle as well. She did not provide testimony regarding any symptoms or problems directly related to her service-connected left fourth metatarsal disability. II. Analysis Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7. Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. 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 (2012). If the evidence of record supports it, staged ratings may also be assigned for different periods over the course of the pendency of the appeal for previously service-connected disabilities. Hart v. Mansfield, 21 Vet. App. 505 (2007). In the case of an appeal of an initial disability rating, as is the case for the Veteran's scar of the right wrist disability, the question of staged ratings is for consideration from the date of the claim in November 2009. Fenderson v. West, 12 Vet. App. 119 (1999). CTS of the right wrist The Veteran has been evaluated for her major arm disability of right wrist CTS under Diagnostic Code 8515. 38 C.F.R. § 4.124a (2012). Diagnostic Code 8515 relates to impairments of the median nerve and provides for a 70 percent disability of the major arm for complete paralysis of the nerve. Complete paralysis is defined as inclination of the hand to the ulnar side with the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, and the thumb in the plane of the hand (ape hand); incomplete and defective pronation of the hand with the absence of flexion of the index finger, feeble flexion of the middle finger, inability to make a fist, and index and middle fingers that remain extended; inability to flex the distal phalanx of the thumb with defective opposition and abduction of the thumb at right angles to the palm; weakened flexion of the wrist; and pain with trophic disturbances. 38 C.F.R. § 4.124a. A 50 percent rating is for application where there is incomplete but severe paralysis of the median nerve. The Veteran is currently rated at the 30 percent level for a moderate, incomplete paralysis of the median nerve. Id. The Veteran was granted a 30 percent rating for her right CTS in December 1999. The medical evidence at that time showed she complained of numbness in the tips of her fingers and thumb and sometimes in the dorsum of the palm of her hand. She also had aching and would occasionally drop small objects without it being immediately apparent. The objective evidence showed there was no evidence of atrophy, either in the thenar or hypothenar as well as the muscles of the right hand or fingers. There was absent sensation to touch dorsally and ventrally and over the dorsal and ventral surfaces of the fingers and thumb in a glove-like fashion. The Veteran complained of similar symptoms in 2006 as noted in several VA outpatient entries. EMG/NCV testing in August 2006 showed moderate carpal tunnel entrapment. The VA examination of July 2007 noted findings of sensory disturbance but no limitation of motion or function of any of the fingers of the right hand or the right wrist. The Veteran did not seek follow-up for her CTS at VA. She was evaluated by Dr. Ekstrom beginning in May 2009. The June 2009 letter from Dr. Ekstrom summarizes the status of the Veteran's disability. The Veteran complained of numbness and pain in her hands and wrists. She was now dropping objects and had swelling that was mostly in the right thumb and fingers. She also reported being awakened at night with numbness and tingling. The Veteran had a full range of motion of the wrist. Her grip strength and muscle bulk were said to be intact. She underwent a right carpal tunnel release on June 19, 2009. The Veteran did not report any further treatment or evaluation from Dr. Ekstrom after August 2009. Further, she did not report any additional VA treatment for her right CTS. The VA records from 2011 to 2012 note her carpal tunnel syndrome only by history. The October 2011 QTC examination provided a report of the Veteran's subjective symptoms and in-depth findings of the physical examination. The Veteran continued to express the same subjective symptoms of tingling and numbness in her hands and fingers without weakness. The objective findings showed no outward physical impairment of the right hand, fingers or wrist. The examiner listed detailed findings for measuring the range of motion of each finger and the joints for each finger. The results were all within normal limits. Repetitive testing did not reveal any decrease in the ranges of motion and there was no evidence of pain, fatigue, weakness, lack of endurance or incoordination. The Veteran has testified as to her having difficulty in picking up and holding on to objects. She experiences numbness in her fingers. She also said she had difficulty in holding on to a steering wheel of a car due to her symptoms. The Board has reviewed the evidence of record, to include from when the Veteran was granted her 30 percent rating in December 1999. The evidence does not support an increased rating at any time during the pendency of the current appeal, to include in the year prior to the current claim. The only exception being for the period of the temporary 100 percent rating from June 19, 2009, to August 1, 2009. The Veteran's symptomatology has remained essentially unchanged since 1999. She complained of pain and numbness and tingling in her right hand and fingers with her current claim. Other than her treatment from Dr. Ekstrom, she has not sought treatment for her right CTS during the pendency of the current appeal. The Board acknowledges the Veteran's reports of symptoms; however, the objective evidence of record does not support a finding that she has severe incomplete paralysis of the right median nerve to warrant a 50 percent rating. Further, the objective evidence reflects no other impairment to the function of the right wrist, hand or fingers aside from the neurological complaints provided by the Veteran. Based on a review of the evidence of record, the claim for an increased rating is denied. Residuals of Fracture of the Left 4th Metatarsal The Veteran suffered a fracture of the left 4th metatarsal in service in 1983. The STRs do not reflect any lingering residuals from the injury. The initial VA examination in 1989 did not find evidence of any residuals and the Veteran was granted a noncompensable rating in 1989. The Veteran's disability has been rated under Diagnostic Code 5284 for disabilities involving the foot other than the several very specific diagnostic codes listed under 38 C.F.R. § 4.71a. Under Diagnostic Code 5284 a moderate disability of the foot warrants a 10 percent rating. A 20 percent rating is for application for a moderately severe disability. Finally, a 30 percent rating is for consideration where there is a severe foot disability. The Veteran has several other service-connected disabilities that involve her left foot. This includes her bunionectomy of the first left toe as well as residuals of her fractured ankle. Through the several VA podiatry entries, pain associated with those two disabilities has been clearly identified. The same is true in the private podiatry records submitted by the Veteran or obtained by VA. However, there are no records to objectively show any identified impairment associated with the left 4th metatarsal disability. The Veteran related that she experienced pain and burning in her toe at the time of her QTC examination but this was subjective. The examiner stated that there were no identifiable residuals on physical examination. The Veteran testified about problems with her left "foot" at her hearing. When asked specifically about her left 4th metatarsal she testified about her bunionectomy. She did not articulate any specific problem with her left 4th metatarsal. As to her difficulty in driving her car, to include it being a stick shift, her left knee replacement surgery appears to be the main factor here. E.W. testified about the Veteran's limitations since her left knee surgery. There is no objective evidence that the left 4th metatarsal has affected the Veteran's ability to drive. Upon review of the evidence of record, the Board finds that the objective evidence of record is more probative of the Veteran's disability. That evidence remains unchanged since the initial grant of service connection in 1989 - no identifiable residuals associated with the fracture of the left 4th metatarsal. Accordingly, no increased rating is warranted for the Veteran's disability during the pendency of the appeal. Finally, the Veteran is not entitled to a compensable disability rating under Diagnostic Code 5283 because the Veteran does not have malunion or nonunion of tarsal or metatarsal bones. Scar of the Right Wrist Disabilities involving scars are evaluated under diagnostic codes listed for disabilities of the skin found at 38 C.F.R. § 4.118 (2012). In that regard, Diagnostic Code 7800 is applicable to scars of the head, neck and face; the residual scarring in this case is to the palm of the Veteran's right hand. The Board therefore finds that Diagnostic Code 7800 is not applicable in this case. The Veteran's scar disability has been evaluated under Diagnostic Code 7801. This diagnostic code is used to rate disabilities involving burn scars or scars due to other causes not of the head, face, or neck that are deep and nonlinear. The Board is not certain as to why the RO selected this diagnostic code as the Veteran's scar has been described as linear and superficial. In any event, under Diagnostic Code 7801, a 10 percent disability evaluation is assigned when a scar, of an area other than the head, face, and neck, is deep or causes limited motion, and involves an area or areas of at least 6 square (sq.) inches (39 square cm.), but less than 12 sq. inches (77 sq. cm.). A 20 percent disability evaluation is warranted for when the scar involves an area or areas of at least 12 sq. inches (77 sq. cm.), but is less than 72 sq. inches (465 sq. cm.). A 30 percent disability evaluation is warranted when the scar involves an area or areas at least 72 sq. inches (465 sq. cm.), but less than 144 sq. inches (929 sq. cm.). A 40 percent evaluation is warranted when the scar involves an area or areas is at least 144 sq. inches (929 sq. cm.), or greater. See 38 C.F.R. § 4.118, Diagnostic Code 7801 (2012). Note (1) indicates that a deep scar is one associated with underlying soft tissue damage. The Veteran's scar, as noted, is not deep. The scar measures 4.2-cm-0.1-cm. The scar does not meet any of the area criterion listed under Diagnostic Code 7801 to warrant a higher rating. Other potentially applicable codes in this case are Diagnostic Codes 7802 and 7804. Under Diagnostic Code 7802, a 10 percent disability evaluation is assigned when a scar, of an area other than the head, face, and neck, that is superficial and nonlinear, and involves an area or areas at least 144 sq. inches (929 sq. cm.), or greater. See 38 C.F.R. § 4.118, Diagnostic Code 7802 (2012). Note (1) indicates that a superficial scar is one not associated with underlying soft tissue damage. Here, the evidence does not reflect the Veteran's surgical scar to approach the dimensions required for consideration of a 10 percent rating under Diagnostic Code 7802. Under Diagnostic Code 7804, a 10 percent evaluation is assigned for 1 or 2 unstable or painful scars; a 20 percent evaluation is assigned for 3 or 4 unstable or painful scars; and, a 30 percent evaluation is assigned for 5 or more unstable or painful scars. See 38 C.F.R. § 4.118, Diagnostic Code 7804 (2012). Note (1) indicates that an unstable scar is one where, for any reason, there is frequent loss of covering over the scar. Additionally, if one or more scars are both unstable and painful, an extra 10 percent will be added to the evaluation that is based on the total number of unstable or painful scars. See Id., Note (2). There is no objective evidence of a painful or unstable scar. The October 2011 QTC examination report noted the scar as not painful on examination. There was no skin breakdown. The scar was described as superficial with no underlying tissue damage. There was no inflammation, edema, or keloid formation. The examiner said the scar was not disfiguring. The Veteran was asked by her representative at the hearing as to whether the scar was painful. The Veteran did not testify that it was. Rather, she said her hand was painful. The objective evidence is more probative in this regard as the examiner thoroughly examined the Veteran's scar with specific attention paid to whether the scar was painful or unstable. The examiner firmly stated that the scar was not. Moreover, there is no other evidence of record to show that the scar is either painful or unstable. A higher rating under Diagnostic Code 7804 is not available at any time during the pendency of the appeal. Diagnostic Code 7805 directs that other scars, and other effects of scars that are evaluated under the above diagnostic codes are to have any disabling effects, not covered by any of the other scar codes, rated under an appropriate diagnostic code. 38 C.F.R. § 4.118 (2012). In short, any additional disability, not covered by the previously discussed diagnostic codes should be rated based on the part affected. In this case, the Veteran's scar does not limit the Veteran's right wrist, hand or fingers. This is confirmed by the QTC examination report that provided extensive details as to the status of the Veteran's wrist, hand and fingers. This included ranges of motion, function and strength. The examiner stated that there was no limitation of function due to the scar. The Veteran has not alleged any such limitation. Her statements and testimony has been that she has a painful scar that would warrant a 10 percent rating. The objective evidence of record is, again, more probative than the Veteran's lay statements. The evidence does not support a compensable rating through application of Diagnostic Code 7805 at any time during the pendency of the appeal. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting an increased or higher rating for any issue on appeal for any period during the pendency of the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). The Board has also considered whether the Veteran's disabilities are so exceptional as to require consideration of an extraschedular rating. 38 C.F.R. § 3.321(b) (1) (2012). In that regard, the Board notes that the Veteran has not been employed at any time during the pendency of his appeal. In Thun v. Peake, the Court held that determining whether a claimant is entitled to an extraschedular rating is a three-step inquiry. 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first step is to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. If the adjudicator determines that this is so, the second step of the inquiry requires the adjudicator to "determine whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Id. at 116. Finally, if the first two steps of the inquiry have been satisfied, the third step requires the adjudicator to refer the claim to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether an extraschedular rating is warranted. Id. In this case, the schedular criteria are adequate to address the Veteran's level of disability for her disabilities of right wrist CTS, fracture of the left 4th metatarsal and scar, associated with CTS of the right wrist. Her disability evaluations are recognition of the severity of impairment of her individual disabilities. The Veteran's subjective and objective symptoms are contemplated in the rating criteria and are allowed for in her disability ratings. Her right CTS is rated at the moderate level based on the symptomatology alleged by the Veteran as well as the objective findings in examination and treatment reports. Her neurological symptoms are recognized as resulting in a moderate, incomplete paralysis of the median nerve. The objective evidence of record does not reflect impairment outside of the neurological aspect of her disability. The disability of the left 4th metatarsal has not been shown to have any identifiable residuals since it was first service-connected in 1989. The Veteran's scar disability has been thoroughly evaluated. The scar is the result of a surgical procedure to alleviate symptoms of the Veteran's right CTS disability. There is no evidence of problems with the scar in the records from Dr. Ekstrom and the October 2011 examination report clearly set forth the size, shape and depth of the scar as well as the lack of any instability or pain associated with the scar. There is nothing unusual in the Veteran's specific case of complaints of pain, tingling and numbness in her right hand and fingers as that is associated with right wrist CTS. Further, absent any objectively identifiable residual related to the left 4th metatarsal, there is no basis to consider an extraschedular rating. Finally, the Veteran's scar is not unique. It is related to routine surgery and has not been shown to meet any of the criteria necessary for a compensable rating. In light of these findings there is no requirement to proceed with the next two steps in consideration of an extraschedular rating. Thun, 22, Vet. App. at 116. ORDER Entitlement to a disability rating in excess of 30 percent for service-connected CTS of the right wrist, except for the period from June 19, 2009, to August 1, 2009, is denied. Entitlement to a compensable disability rating for service-connected residuals of a fracture of the left 4th metatarsal is denied. Entitlement to an initial compensable disability rating for service-connected scar associated with CTS of the right wrist is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs