Citation Nr: 1318572 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 08-00 952 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for right wrist tendonitis. 2. Entitlement to an initial rating in excess of 10 percent for left wrist tendonitis. 3. Entitlement to service connection for rheumatoid arthritis. 4. Entitlement to service connection for Raynaud's disease. 5. Entitlement to a total disability rating due to individual unemployability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. M. Schaefer, Counsel INTRODUCTION The Veteran served on active duty from August 1984 to June 1990. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from rating decisions issued in February 2007 and December 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. In April 2013, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge, via videoconference. A transcript of the hearing is associated with the claims file. In April 2012, the Veteran submitted a claim to reopen the previously denied claim of entitlement to service connection for posttraumatic stress disorder. This issue has not been adjudicated by the RO and so is referred to the RO for appropriate action. Subsequent to the most recent Supplemental Statement of the Case (SSOC), the Veteran submitted additional evidence and has waived RO consideration of that evidence. 38 C.F.R. § 20.1304(c) (2012). The issues of entitlement to service connection for Raynaud's disease and entitlement to TDIU are addressed in the remand portion of the decision below and are remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At its most severe, the Veteran's right wrist tendonitis is manifested by dorsiflexion to 35 degrees and plantar flexion of 40 degrees. 2. At its most severe, the Veteran's left wrist tendonitis is manifested by dorsiflexion to 40 degrees and plantar flexion of 40 degrees. 3. The competent medical evidence does not establish a current diagnosis of rheumatoid arthritis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right wrist tendonitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5215 (2012). 2. The criteria for a rating in excess of 10 percent for left wrist tendonitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5215 (2012). 3. Rheumatoid arthritis was not incurred in the Veteran's active duty military service. 38 U.S.C.A. § 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes certain duties upon VA to notify the claimant of the shared obligations of the claimant and VA in developing his or her claim and to assist the claimant by making reasonable efforts to obtain relevant evidence in support of the claims. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Here, the Veteran is appealing the initial rating assignment for her right and left wrist disabilities. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, so any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, thereafter, once a notice of disagreement (NOD) has been filed, for example contesting a downstream issue such as the initial rating assigned for the disability, only the notice requirements for a rating decision and statement of the case (SOC) described in 38 U.S.C. §§ 5104 and 7105 control as to the further communications with the Veteran, including as to what evidence is necessary to establish a more favorable decision with respect to downstream elements of the claim. 38 C.F.R. § 3.159(b)(3) (2012). The RO has provided the Veteran with the required SOC discussing the reasons and bases for not assigning a higher initial rating and citing the applicable statutes and regulations. With respect to the service connection claim for rheumatoid arthritis, the Board notes that VCAA notice must be provided before the initial unfavorable AOJ decision on the claims for VA benefits. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was provided with a VCAA notification letter in May 2007, prior to the initial unfavorable AOJ decision issued in December 200709. The pre-adjudicatory VCAA notice informed the Veteran of the evidence necessary to establish service connection, of how VA would assist her in developing the claim, and her and VA's obligations in providing such evidence for consideration. This letter also included information regarding the substantiation of disability ratings and effective dates. Therefore, the Board finds that the Veteran received all necessary VCAA notice prior to the initial adjudication of her service connection claim. Accordingly, the Board determines that the content requirements of VCAA notice have been met and the purpose of such notice, to promote proper development of the claim, has been satisfied. See Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). Based on the above, the Board finds that further VCAA notice is not necessary prior to the Board issuing a decision. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Veterans Law Judge or Decision Review Officer 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. Here, during the Board hearing, the Veteran gave extensive testimony as to her current wrist symptoms and the impact of those symptoms on her daily life. The VLJ and the accredited representative from the Missouri Veterans Commission asked questions to ascertain the existence of outstanding treatment evidence, as well as to clarify her symptomatology. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative. With regard to the service connection claim, the Veteran's representative indicated that the Veteran does not believe she has rheumatoid arthritis, which she had also stated in a written submission that is in the claims file. No testimony was offered or elicited as to this claim. The lack of diagnosed disability is borne out by the medical evidence of record. Thus, even though the Veteran did not formally withdraw the claim for service connection for rheumatoid arthritis, there was in essence no claim to prove. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). VA has also fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims and providing her with a VA examination. The Veteran's service treatment records, VA medical records, private treatment records, Social Security Administration (SSA) disability records, and the reports of October 2005, June 2009, and September 2010 fee-basis examinations and June 2012 and September 2012 VA examinations were reviewed by both the AOJ and the Board in connection with adjudication of the claims. The Veteran has not identified any additional, relevant treatment records the Board needs to obtain for an equitable adjudication of the claims. With regard to the VA examinations, the Board notes that once VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, each examiner reviewed the claims file, documented the Veteran's subjective complaints and medical history, and evaluated the Veteran. Thereafter, in the reports, they provided information sufficient in detail and relevance to the rating criteria to allow for determination of the appropriate disability ratings for the right and left wrists. Nothing suggests that any examiner documented findings inconsistent with the medical history outlined in the claims file. Thus, the Board does not find any of the examinations to be inadequate. The Board observes that no VA examination was conducted to assess the existence and etiology of the rheumatoid arthritis. However, as the Veteran does not have the disability, there is no disability for which an etiological opinion need be obtained. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159 (c)(4). In light of the above, the Board concludes that the medical evidence of record is sufficient to adjudicate the Veteran's claims without further development and additional efforts to assist or notify the Veteran in accordance with VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). Therefore, the Board determines that the Veteran will not be prejudiced by the Board proceeding to the merits of the claims. II. Initial Rating claims Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. As such, the Board has considered all evidence of record in evaluating the Veteran's benign positional vertigo disability. Also, in Fenderson, the Court discussed the concept of the "staging" of ratings, finding that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson at 126-28. As such, in accordance with Fenderson, the Board has considered the propriety of staged ratings in evaluating the Veteran's service-connected disability. Where there is a question of which of two rating evaluations shall be applied, the higher evaluation will be assigned if the disability picture more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Rating evaluations for shoulder, arm, hand, and related neurological disabilities are dependent on whether the arm involved is the major or minor, i.e., whether it is related to the dominant or nondominant hand. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. In this case, the Board observes that multiple VA examination reports indicate that the Veteran is right-handed. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. The Veteran's service-connected right and left wrist disabilities are assigned a 10 percent rating each, pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5215. The 10 percent is assigned for limitation of motion resulting from tenosynovitis. Under Diagnostic Code 5024, tenosynovitis is to be rated on limitation of motion of the affected part. Under Diagnostic Code 5215, limitation of motion of the wrist, either major or minor, the maximum 10 percent rating is assigned when there is limitation of motion of the wrist with dorsiflexion (extension) less than 15 degrees or with palmar flexion limited in line with the forearm. There is no higher disability evaluation available under Diagnostic code 5215. For a rating in excess of 10 percent, ankylosis of the wrist must be present. 38 C.F.R. § 4.71a. Normal wrist range of motion is from 80 degrees flexion to 70 degrees extension, with normal ulnar deviation to 45 degrees and normal radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. Evidence relevant to the appeal period includes VA treatment records and the reports of October 2005, June 2009, and September 2010 fee-basis examinations and June 2012 and September 2012 VA examinations. The private treatment records in the file are dated prior to the appeal period. The Board notes that VA treatment records do not reflect treatment for the Veteran's wrists, and she has denied receiving treatment when asked. At the October 2005 VA examination, the Veteran presented with discomfort in the wrists and weakness in the fingers and an inability to write without difficulty. Clinical examination revealed both wrists to be within normal limits in appearance. Range of motion for both wrists was dorsiflexion 70 degrees, palmar flexion 80 degrees, radial deviation 20 degrees, and ulnar deviation 45 degrees without additional limitation due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The neurological examination was within normal limits. X-rays were within normal limits. At a June 2009 fee-basis examination, the Veteran reported weakness, stiffness, and fatigability in the wrists. She denied having swelling, heat, redness, giving way, lack of endurance, locking, deformity, tenderness, drainage, effusion, subluxation, pain, and dislocation. The Veteran indicated that she had flare-ups multiple times per day, precipitated by temperature. She denied incapacitation. Functional impairment described included writing, typing, and continuous use, using tools like a car wash wand, weed eater, and chainsaw, skiing, driving, and coordinating fingers. Both wrists showed tenderness without edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, and subluxation. Range of motion was to 65 degrees dorsiflexion on the right and to 60 degrees on the left. Palmar flexion was to 70 degrees bilaterally, radial deviation was to 20 degrees bilaterally, and ulnar deviation was to 40 degrees bilaterally. No further loss of range of motion for either wrist occurred with repetition, but the examiner stated that joint function was additionally limited by pain after repetitive use, but not by fatigue, weakness, lack of endurance, and incoordination. X-rays were within normal limits. At the September 2010 QTC examination, the Veteran endorsed weakness, stiffness, swelling, lack of endurance, fatigability, tenderness, and pain. She denied heat, redness, giving way, locking, deformity, drainage, effusion, subluxation, and dislocation. She indicated that flare-ups may occur as often as three times per day and last for three hours. Both wrists showed tenderness without edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, and subluxation. The examiner stated there was no ankylosis of the left wrist, but did not comment with respect to the right wrist. Specific range of motion measurements were not provided. The examiner merely stated that range of motion was within normal limits and that pain began with palmar flexion at 80 degrees. No additional loss of function was found on repetition. X-rays were within normal limits. In June 2012, the Veteran's wrists were again examined. The Veteran reported that pain radiates to her forearm, made worse by writing or typing. She stated that she sometimes has instant sharp pain when writing and has to stop. She indicated that she has daily pain with activity, including opening jars and doing dishes. The Veteran reported that cold weather made her wrists and forearms painful. Right wrist range of motion was dorsi and palmar flexion to 55 degrees each. Pain occurred with dorsiflexion at 30 degrees; there was no evidence of painful motion with palmar flexion. Left wrist range of motion was 60 degrees palmar flexion with pain at 55 degrees and 70 degrees dorsiflexion with pain at 55 degrees. There was no additional functional loss with repetition. Functional impairment was due to pain on movement. Muscle strength with flexion, extension, and grip was 5/5. The Veteran indicated pain was greater on the right with grip and radiated to the mid forearm. There was pain to palpation over the forearms, but not the wrists, and no sign of carpal tunnel syndrome. The examiner stated that imaging showed traumatic arthritis in both wrists, but clarified in July 2012 that the arthritis was in the intercarpal joints at the base of the thumbs and first fingers, not the wrists. At a September 2012 VA examination, the examiner found right wrist range of motion was dorsi and palmar flexion to 40 degrees each. Pain occurred with dorsiflexion at 40 degrees and with palmar flexion at 35 degrees. Left wrist range of motion was to 40 degrees for both palmar and dorsi flexion with pain occurring at 40 degrees. There was no additional functional loss with repetition. Functional impairment was due to less movement than normal, weakened movement, excess fatigability, and pain on movement. Muscle strength was 4/5 bilaterally. There was no ankylosis of either wrist. Imaging studies showed no arthritis. The examiner stated the wrist tendonitis on both sides was moderate. Based on the above, the Board determines that a rating in excess of 10 percent each for the right and left wrist disabilities is not warranted. The 10 percent rating is the maximum available for limitation of motion of the wrist without evidence of ankylosis, which the evidence establishes is not present. The Board has considered the effect of pain, fatigue, weakness, lack of endurance, incoordination, and flare-ups. A 10 percent rating is warranted for dorsiflexion to 15 degrees or palmar flexion even with the forearm, or 0 degrees. See 38 C.F.R. § 4.71a, Plate I. The Veteran's range of motion exceeds this degree of limitation even with consideration of pain, being limited to no less than 35 degrees dorsiflexion and 40 degrees palmar flexion with consideration of pain. Therefore, the 10 percent rating assigned contemplates further loss of function that may occur due to repetition and flare-ups. The Board has considered the Veteran's statements in support of her claim and her contentions that she has additional disability that accounts for her symptoms other than tendonitis and that additional ratings are warranted for those disabilities. The Board notes that the claim for Raynaud's disease is addressed separately in the Remand below. Contemplation has been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4 (2012), as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The record fails to demonstrate ankylosis of the wrist to warrant a higher rating under Diagnostic Code 5214, and as discussed X-rays do not reveal the presence of arthritis. Further, even if arthritis were present, a rating for arthritis is warranted only if limitation of motion of the joint is otherwise not compensated, which is not the case here. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Moreover, the record does not establish additional disabilities that may be the cause of the Veteran's symptoms, such as carpal tunnel syndrome. In this regard, the Board notes that neurological examinations have been normal and a November 2004 EMG did not show carpal tunnel syndrome. In light of the above, the Board concludes that an initial rating in excess of 10 percent for right wrist tendonitis and an initial rating in excess of 10 percent for left wrist tendonitis are not warranted. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). However, in the present case, the preponderance of the evidence is against the Veteran's claims of entitlement to higher initial ratings for her wrist disabilities. Therefore, the claims are denied. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extra-schedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned rating inadequate. Bilateral wrist tendinitis is rated based on the limitation of motion caused by the tendinitis, which criteria the Board has found to specifically contemplate the level of occupational and social impairment caused by this disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5215. The Veteran's bilateral wrist disability is manifested by painful motion. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are congruent with the disability picture represented by the 10 percent disability ratings assigned by the RO. Evaluations in excess of those assigned are provided for certain manifestations of wrist disabilities, but as noted above, the evidence demonstrates that those manifestations are not present in this case. The criteria for the 10 percent ratings assigned by the RO reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extra-schedular consideration is not required. See 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5215; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). III. Service Connection Service connection may be granted for disability arising from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr, 21 Vet. App. at 309. The Veteran has raised a claim of entitlement to service connection for rheumatoid arthritis. At her hearing in March 2013, her representative indicated that he and the Veteran had discussed this disability prior to the hearing and the Veteran did not believe she had rheumatoid arthritis. In a December 2012 written submission, the Veteran stated clearly that she does not have rheumatoid arthritis and it need not be discussed at the hearing. The Board observes that the Veteran is competent to describe symptoms and facts of which she has direct knowledge. See Jandreau v. Nicholson, 492 F.3d. 1372 (Fed. Cir. 2007). However, she did not at any time expressly withdraw this issue from appellate consideration; therefore, the merits of this issue are still before the Board. Consistent with the Veteran's assertions, both in-service and post-service treatment records are silent for a diagnosis of rheumatoid arthritis. VA treatment records contain several notes labeled as "Rheumatology/Arthritis Note," but these notes are not specific to rheumatoid arthritis. Rather, they address the Veteran's various orthopedic complaints related to her back, shoulders, wrists, and hands. Thus, the Veteran does not have a diagnosed disability of rheumatoid arthritis. Where there is no disability, there can be no entitlement to compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the Veteran does not have a current disability of rheumatoid arthritis or a disability at any time during the claim period (see McClain v. Nicholson, 21 Vet. App. 319 (2007)), there is no disability which can be related to service. Entitlement to service connection for rheumatoid arthritis is denied. ORDER An initial rating in excess of 10 percent for right wrist tendonitis is denied. An initial rating in excess of 10 percent for left wrist tendonitis is denied. Entitlement to service connection for rheumatoid arthritis is denied. REMAND Regrettably, the Board determines that a remand is necessary with regard to the issues of entitlement to service connection for Raynaud's disease and TDIU. The Veteran was afforded a fee-basis QTC examination in April 2011 to assess the existence and etiology of the claimed Raynaud's disease. The examiner provided a list of in-service and post-service treatment notes considered. Among these notes was an orthopedics note by Dr. Bulley from August 24, 1989. The examiner stated that this treatment note indicated a "[h]istory of three months of right hand weakness; wrist tendonitis diagnosed then; use of night splints, Feldene with some improvement. Normal exam. No mention of Raynaud's phenomenon." However, this August 1989 treatment note, in fact, states that the Veteran "describes symptoms and signs very consistent with Raynaud's phenomenon." A September 2012 VA hand examination report also states that there is no evidence of Raynaud's by history. Thus, the Board determines that the thoroughness of the review of the claims file by the April 2011 QTC examiner and September 2012 VA examiner is in question, which renders the examinations inadequate. Barr, 21 Vet. App. at 311. Accordingly, the Board determines that the issue of entitlement to service connection for Raynaud's disease must be remanded so that another VA examination may be scheduled. As for the Veteran's claim of entitlement to TDIU, the United States Court of Appeals for Veterans Claims has held that all issues "inextricably intertwined" with an issue certified for appeal are to be identified and developed prior to appellate review. Harris v. Derwinski, 1 Vet. App. 180 (1991). The outcome of the Veteran's TDIU claim is impacted by the disability ratings assigned to the Veteran's service-connected disabilities; thus, the TDIU claim is considered to be inextricably intertwined with the increased rating claim. Consequently, the claim of entitlement to a TDIU rating must be remanded to the AOJ in accordance with Harris. Moreover, the Board finds that another VA examination to assess the Veteran's employability should be scheduled. In June 2012, a VA examiner stated that the Veteran has difficulty gripping and opening her hands with any physical labor or used of her hands for more than an hour. He indicated that typing or writing will cause the same symptoms. The examiner opined that the Veteran will have to stop work due to this problem, but the Board is unclear whether the examiner meant the Veteran would have to stop what she was doing at that moment or not be employed. The examiner did not indicate what sort of work the Veteran could do in light of her wrist disabilities. In light of these facts, the Board determines that the Veteran should be scheduled for another VA examination to assess her ability to obtain and maintain substantially gainful employment. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for another VA examination to assess the existence and etiology of her Raynaud's disease. The claims file should be made available for review, and the examination report should reflect that such review occurred. All pertinent symptomatology and findings must be reported in detail. All tests or studies necessary to make these determinations must be conducted. Upon a review of the record and examination of the Veteran, the examiner should respond to the following: a. Does the Veteran have now, or at any time during the appeal period, had Raynaud's disease? b. If the examiner determines that a diagnosis of Raynaud's disease is appropriate, is it at least as likely as not (50 percent probability or more) that the disability is causally or etiologically a result of her military service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. A complete rationale for any opinion advanced must be provided. The examiner must not only document the Veteran's self-reported history of Raynaud's symptoms as discussed in the claims file and at the examination, but he or she must consider and discuss those complaints in the opinion. The examiner must also specifically address the suspicion of Raynaud's disease discussed in the August 1989 treatment note. 2. The Veteran must be provided an evaluation by a VA vocational rehabilitation specialist to determine the effect of her service-connected disabilities on her ability to secure or follow a substantially gainful occupation. The claims file should be made available for review, and the report should reflect that such review occurred. The vocational rehabilitation specialist must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on the evidence of record, the evaluation of the Veteran, and with consideration of the Veteran's statements, the specialist must provide an opinion as to whether the Veteran's service-connected disabilities alone or acting in concert, preclude her from securing and following a substantially gainful occupation consistent with her education and occupational experience. This opinion must be provided without consideration of either her nonservice-connected disabilities or age. A complete rationale for the opinion advanced must be provided 3. Notify the Veteran that she must report for the examination and cooperate in the development of the claim. Failure to report for a VA examination without good cause may result in denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 4. Readjudicate the issues on appeal. If any benefit sought on appeal remains denied, issue an additional Supplemental Statement of the Case. If in the course of adjudicating this claim, the RO finds that the rating criteria under 38 C.F.R. § 4.16(a) (2012) have not been met, but the Veteran's service-connected disabilities prevent her from following a substantially gainful occupation, the RO should refer the appeal to the Chief Benefits Director or the Director, Compensation and Pension Service, for extra-schedular consideration on the issue of entitlement to TDIU. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran and her representative. After they have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs