Citation Nr: 1320646 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 05-06 095 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for left carpal tunnel syndrome. 2. Entitlement to an increased rating in excess of 10 percent as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1980 to January 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In February 2006, the Veteran testified at a local hearing before a Decision Review Officer (DRO). A copy of the transcript is of record. In an October 2009 decision, the Board remanded the claims for additional development and adjudicative action. The case was returned to the Board for further appellate review, and in a July 2011 decision, the Board, in pertinent part, (1) denied an increased rating in excess of 10 percent prior to May 24, 2006 for postoperative residuals of a right knee injury, (2) assigned a separate 10 percent rating as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury, and (3) granted an initial rating of 10 percent, but no more, for left carpal tunnel syndrome for the entire initial rating period on appeal. The Veteran appealed the Board's July 2011 decision for these issues to the United States Court of Appeals for Veterans Claims (Court). By order dated January 2013, the Court granted a Memorandum Decision, set aside the July 2011 Board decision for the issues of (1) an increased rating in excess of 10 percent as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury and (2) an initial rating in excess of 10 percent for left hand carpal tunnel syndrome, and remanded these issues to the Board for compliance with the terms of the Memorandum Decision. The two issues that were granted in the Board's 2011 decision remain undisturbed. That is, the Board assigned a 10 percent rating for left carpal tunnel syndrome back to February 1, 2004, and assigned a separate 10 percent rating as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury. The carpal tunnel rating increase was effectuated in a July 2011 rating decision, but it does not appear that the RO has effectuated the separate rating for the left knee, perhaps because this was mistakenly left off the Board's Order. Although this issue is being remanded, as discussed below, the RO should take this opportunity to implement the Board's prior grant and assign a 10 percent rating for limitation of motion due to arthritis under Diagnostic Code 5003 as of May 24, 2006. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issue of an increased rating in excess of 10 percent as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal for the issue of an initial rating in excess of 10 percent for left carpal tunnel syndrome has been obtained. 2. For the entire initial rating period on appeal, the service-connected left carpal tunnel syndrome more closely approximates a manifestation of mild numbness in the fingers that is productive of no more than mild paralysis of the median nerve and limitation of motion without favorable ankylosis in 20 degrees to 30 degrees dorsiflexion. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for left carpal tunnel syndrome have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.21, 4.40, 4.45, 4.59, 4.124a, Diagnostic Codes 8515, 8615 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Regarding the issue relating to left carpel tunnel syndrome, the rating decision on appeal granted service connection and assigned the disability rating and effective date for the award. Therefore, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. at 473. A January 2005 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased rating; while March 2008 and January 2011 supplemental statements of the case (SSOC) readjudicated the matters after the Veteran and his representative responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield, 20 Vet. App. at 542. The Veteran has had ample opportunity to respond and supplement the record. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (holding that "where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). With regard to the duty to assist, the Veteran's service treatment records and pertinent post-service treatment records, including records utilized by the Social Security Administration in a claim for benefits have been secured. The RO arranged for VA examinations in May, and October 2004; May 2006; October 2008; February 2010; January 2011; and March 2012. [Incidentally, the 2012 examination was performed in connection with another claim, but contained findings relevant to this claim. The RO did not issue a SSOC because the pending claim for an increase was with the CAVC at that time. However, the Veteran's representative has waived RO consideration of the 2012 examination, so the Board can consider this evidence in the first instance.] The February 2010 and January 2011 examinations were performed pursuant to the Board's October 2009 remand and in compliance with the Remands instructions in that the nature and severity of the Veteran's disabilities were described. The Veteran has not identified any evidence that remains outstanding. VA's duty to assist is met. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Disability Rating Legal Criteria Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155 (West 2002). Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). When entitlement to compensation has been established and a higher initial evaluation is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of the Veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). 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. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. Id. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating, and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. 38 C.F.R. § 4.59. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Id. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. Analysis for Left Carpal Tunnel Syndrome Pursuant to the January 2013 Memorandum Decision, the Court held that a remand is required for the Board to evaluate, in the first instance, the Veteran's lay evidence with respect to the service-connected carpal tunnel syndrome. If the Board determines that the Veteran's lay evidence is competent and credible, then it must address whether the lay evidence alone is sufficient to support an increased rating for the Veteran's condition at any point after May 24, 2006. The Veteran's original claim for compensation benefits was submitted in October 2003, prior to his release from active duty. That claim included the matter involving numbness of his left hand. While he was scheduled for a VA peripheral nerve examination in June 2004, that examination did not include symptoms of the left hand, but was confined to right leg complaints. Service connection for left carpel tunnel syndrome was granted by rating decision dated in August 2004, effective February 1, 2004, the date after the Veteran's discharge from service. The basis for the grant of service connection was that this disability was noted during service. A noncompensable rating was assigned on the basis that the Veteran had not had complaints of this disability subsequent to service. A VA compensation examination was not performed until November 12, 2004. On the basis of this examination, the rating was increased to 10 percent, effective on November 12, 2004, by rating decision dated in January 2005. In a July 2011 decision, the Board assigned a 10 percent disability rating, but no higher, for the entire initial rating period on appeal from February 1, 2004. In furtherance of the January 2013 Memorandum Decision, the Veteran is appealing the assignment of a 10 percent rating for the entire initial rating period on appeal. Pursuant to the rating criteria for diseases of the peripheral nerves, specifically neuritis, the Veteran's service-connected left carpal tunnel syndrome is rated at 10 percent disabling. See 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615 (2012). Diagnostic Code 8515 provides a 10 percent disability rating for incomplete mild paralysis of the major and minor extremity, a 30 percent disability rating for incomplete moderate paralysis of the major extremity, a 50 percent disability rating for incomplete severe paralysis of the major extremity, and a 70 percent disability rating for complete paralysis of the major extremity. Id. At VA examinations in connection with this claim on appeal, the Veteran reported he is left-hand dominant, hence the left hand represents the major extremity. After a full review of the record and consideration of whether the assignment of separate ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against the Veteran's appeal for an initial rating in excess of 10 percent for left carpal tunnel syndrome for any period. For the entire initial rating period on appeal, the service-connected left carpal tunnel syndrome more closely approximates a manifestation of mild numbness in the fingers that is productive of no more than mild paralysis of the median nerve and limitation of motion without favorable ankylosis in 20 degrees to 30 degrees dorsiflexion. An examination was conducted by VA on November 12, 2004. At that time, he had complaints of pain and numbness on the dorsal aspect of the hand and laterally below the index finger. He reported that he had worked with computers for 20 years. He also complained of numbness of the tips of the fingers. He reported that, although he was left-handed, he tried to use his left hand as little as possible. On examination, there was no muscle atrophy or involuntary movements. Power was decreased on the left. Deep tendon reflexes were 1 to 2, bilaterally and symmetrical. Left hand grip weakness was noted as compared to the right. There was decreased pinprick in the left upper extremity, but not in any dermatomal pattern. The impression was carpal tunnel syndrome, left hand, manifested by numbness and pain in the left hand index finger and pain in the finger tips. At the time of the initial neurologic examination following the Veteran's discharge from service, mild numbness of the left fingertips was noted. This meets the criteria for a 10 percent disability rating on the basis of neuritis, but as symptoms of moderate incomplete paralysis were not shown, a rating in excess of the 10 percent rating was not warranted on the basis of this examination. In the 2011 decision, the Board found that under these circumstances, the initial award should be retroactively applied to the day after his discharge from active duty, February 1, 2004. The benefit was granted to this extent in the Board's prior decision and has already been implemented by the RO. An examination was conducted by VA in May 2006. At that time, the Veteran complained of having a sharp pain in the left wrist into the tips of the fingers. These occurred once per week. He used a wrist brace at night, but denied any "trigger." During a flare-up, the pain lasted about 30 minutes. He felt weakness in the left hand as well as numbness in the palmar area all over. He was mainly limited in that he could not lift heavy objects. He reported that he was left handed, but he tried not to use his left hand. On examination, strength in the left hand was 4+/5, which was identical to the strength in the right hand. He had decreased sensation to pinprick in the left forearm and hand that was not in any dermatomal pattern. Range of motion testing of the left wrist was not documented. The Veteran was diagnosed with carpal tunnel syndrome of the left hand. On VA examination in October 2008, the Veteran complained of cramps to the left hand at night and some weakness, fatigue, and functional loss. He noted the pain is a 2/10 and occurs at all digits of the left hand to the left wrist area. The pain occurs on a daily basis and lasts for several hours, and flare-ups of worsening pain as a 7/10 occur with any type of overuse. He described overuse as any precipitating or aggravating factors. The Veteran also noted use of a wrist brace at night and some relief with massage. Upon clinical evaluation, the Veteran exhibited full range of motion of the left wrist on repetitive-use testing. There were no findings of heat, swelling, erythema, pain with motion, or additional limitation of motion, or instability. Tinel and Phalen's signs were also negative. Neurological testing revealed deep tendon reflexes are 2+ and symmetrical and sensations were intact to sharp and dull in all areas. After a review of the claims file and clinical evaluation, the Veteran was diagnosed with left carpal tunnel syndrome. In February 2010, the Veteran was afforded a VA neurologic examination to determine, in pertinent part, the nature and severity of his left carpal tunnel syndrome. The Veteran reported the pain as worse since the last VA examination. Specifically, he noted constant pain in the left hand thenar eminence area, characterized as sharp pain with intensity of 9. He said that he had the pain all the time without flare-ups. He reported that the pain and numbness made it difficult for him to sleep and sometimes woke him from sleep with tingling and numbness. He had no swelling, locking, or giving way. He used a left hand brace, but this did not help. With regard to functional limitation, he reported not doing anything, the pain is exhausting, and feels like he does not have energy. Upon physical examination, the Veteran exhibited palmar flexion to 60 degrees and dorsiflexion to 40 degrees, both limited by discomfort/guarding, mild tenderness and there were no findings of swelling, muscle atrophy, muscle wasting, or contracture. Power was 4 to 4+ out of 5 in the left upper extremity. Tinel and Phalen's signs were negative. Deep tendon reflexes were 1 to 2 bilaterally and symmetrical. There was decreased pinprick sensation along the median distribution of the left upper extremity. X-ray results of the left wrist showed no acute fracture, dislocation, or boy destructive lesion. After a review of the claims file and the clinical evaluation, the examiner characterized the service-connected left carpal tunnel syndrome as mild to moderate and acknowledged the Veteran's subjective symptoms of moderate pain. It was determined that nerve conduction studies were not required because due to the subjective symptoms of constant pain, it is less likely the Veteran would tolerate such studies, and there was mild to moderate functional limitations with physical type of activity, specifically with gripping, carrying, and holding. Nevertheless, the Veteran underwent nerve conduction studies in January 2011. Such studies revealed normal left median and ulnar motor conduction, except for moderate ulnar focal motor slowing across the elbow. The diagnosis following the electrodiagnostic testing was no objective evidence of left carpal tunnel syndrome. Most recently, the Veteran underwent a March 2012 VA DBQ examination for wrist conditions. He reported complaints of left wrist pain on daily basis, numbness to metacarpophalangeal (MCP) joints of index and middle digits left hand without any aggravating or precipitating factors. The Veteran also reported constant shooting pains to the entire left hand, a cramping-type sensation, and increased pain with overuse. He denied any current medical treatment and noted use of a splint for the left wrist every 2-3 days. Upon clinical evaluation, the Veteran exhibited full range of motion of the left wrist, as well as after repetitive-use testing, with no objective evidence of painful motion. He did not demonstrate localized tenderness or pain on palpation of joints/soft tissue of either wrist, ankylosis of the wrist joint, any residual signs and/or symptoms due to arthroscopic or other wrist surgery, or any scars related to the left wrist disability. The examiner indicated the Veteran does not have additional limitation in range of motion of the wrist following repetitive-use testing, nor any functional loss and/or functional impairment of the wrist. There were also no findings of functional impairment of the left wrist such that no effective function remains other than that which would be equally well served by amputation with prosthesis. With regard to any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the left wrist disability, the examiner made the following notations. There was no muscle wasting or atrophy to the upper extremities, negative Tinel's and Phalen's test bilaterally, sensations were intact to sharp and dull touch in both upper and lower extremities, deep tendon reflexes were 2/4 and equal upper extremities. Imaging studies of the wrist revealed no findings of degenerative or traumatic arthritis. Nerve conduction studies of the bilateral upper extremities revealed, in pertinent part, left median and ulnar motor conduction were normal except for moderate ulnar focal motor slowing across the elbow, and median and ulnar sensory nerve action potentials were within normal limits. After a review of the claims file and the clinical evaluation, the March 2012 VA examiner acknowledged the Veteran's complaints of pain and numbness to the left hand and electromyography/nerve conduction velocity (EMG/NCV) results revealed normal left median nerve both motor and sensory, and concluded it is "less likely as not [that] current subjective symptoms are caused by or a result of service-connected left carpal tunnel syndrome. Current medical expertise is not capable of attributing portions of each symptomatology to each etiology." After a review of the evidentiary record for the entire initial rating period, the Board further finds that a higher rating is not warranted for ankylosis of the wrist. Diagnostic Code 5214 provides the following ratings for the major extremity: 30 percent for favorable ankylosis in 20 degrees to 30 degrees dorsiflexion; 40 percent for ankylosis in any other position except favorable; and 50 percent for unfavorable ankylosis in any degree of palmar flexion or with ulnar or radial deviation. 38 C.F.R. § 4.71a (2012). Normal range of motion for the wrist is 80 degrees palmar flexion and 70 degrees dorsiflexion. 38 C.F.R. § 4.71, Plate I (2012). As noted above, there were no objective findings of ankylosis of the left wrist and limited range of motion of the left wrist, at worst, was to 60 degrees dorsiflexion at the February 2010 VA examination. The Board further acknowledges the Veteran's reported history of symptomatology regarding the service-connected left carpal tunnel syndrome and that he is competent to report such symptoms because this requires only personal knowledge as it comes through ones senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). As discussed above, the Veteran reported complaints at the VA examination reports dated November 2004, May 2006, October 2008, February 2010, and March 2012. Moreover, the Veteran reported at the February 2006 DRO hearing that, with regard to the left carpal tunnel syndrome, he experiences pain and an inability to grip things. As a result, the Board finds the Veteran's lay evidence is also credible as he provided consistent reports of symptomatology regarding the service-connected left carpal tunnel syndrome. Nevertheless, the Board finds that such lay evidence, alone, is insufficient to support an initial rating in excess of 10 percent for this disability at any time during the initial appeal period, to include after May 24, 2006. That is because his statements as to the pain he experiences are outweighed by the fact that such pain has not resulted in impaired functioning. Despite complaining of pain with use, he clearly remains able to use the wrist in a somewhat normal manner, since there is no evidence of muscle atrophy, which would indicate a level of disuse for the wrist. Both the 2008 and 2012 examinations showed no decrease in range of motion following repetitive motion testing. As such, there is no basis for a rating in excess of 10 percent. As a result, and after fully considering all the lay and medical evidence regarding the service-connected left carpal tunnel syndrome for the entire rating period, the Board finds that the preponderance of the evidence is against an initial rating in excess of 10 percent for any period. 38 C.F.R. §§ 4.3, 4.7. Additional Considerations The Board has also considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, with respect to the claim as required by the Court. See Schafrath, 1 Vet. App. at 594. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign a rating higher than the currently assigned 10 percent rating for the service-connected left carpal tunnel syndrome for any period on appeal. In July 2011, the Board noted the Veteran's representative requested consideration of a claim for total disability based upon individual unemployability (TDIU) based on the Veteran's September 2005 written statements. After a brief discussion and application of Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) to this case, the Board advised the Veteran that if he desires to pursue this issue, he should do so with specificity at the RO. Moreover, while the Veteran is not employed, and receives Social Security Disability Benefits, a claim for entitlement to a TDIU was denied by an unappealed July 2006 rating decision. Therefore, this matter is not before the Board. Next, an extra-schedular rating may be provided in exceptional cases. 38 C.F.R. § 3.321 (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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. With regard to the service-connected left carpal tunnel syndrome, the schedular rating criteria contemplate the symptoms and impairment caused by this disability. The schedular rating criteria specifically provide for ratings based on paralysis of the median nerve and other factors such as functional limitation. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. There is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, referral for extra-schedular consideration for the service-connected disabilities on appeal is not required. ORDER An initial rating in excess of 10 percent for left carpal tunnel syndrome is denied. [Continued on Next Page] REMAND A remand is required in this case to ensure there is a complete record upon which to decide the issue of an increased rating in excess of 10 percent as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c), (d) (2012); Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). Pursuant to the January 2013 Memorandum Decision, the Court held that a remand is required for the Board to provide an adequate statement of reasons or bases that determines whether the 2006, 2008, and 2010 VA examinations were adequate and whether the Veteran suffers additional functional loss during flare-ups such that a higher disability rating for the right knee injury is warranted. After a review of the claims file, the Board finds an additional VA examination is needed. Accordingly, the issue of an increased rating in excess of 10 percent as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury is REMANDED for the following actions: 1. Schedule the Veteran for the appropriate VA examination to determine the current severity and impairment of his service-connected right knee disability. Any and all indicated evaluation studies and tests deemed necessary by the examiner should be accomplished. All pertinent symptomatology and findings should be reported in detail. The report should list all subjective complaints and objective findings in detail, including range of motion (ROM) testing of the right knee in degrees. The Veteran's claims file should also be made available and reviewed by the examiner. The examination report should reflect that such review was accomplished. The examiner should address the extent of functional impairment attributable to any reported pain. In this regard, the examiner should specifically indicate whether there is any pain and whether there is likely to be additional impairment of the right knee caused by any of the following: (1) pain in use, including during flare-ups; (2) weakened movement; (3) excess fatigability; (4) incoordination. The examiner should describe whether any existing pain significantly limits functional mobility of the right knee during flare-ups or when repeatedly used. The examiner should also report whether the Veteran has any recurrent instability or lateral subluxation of the right knee, and if so, should describe whether such instability or subluxation is slight, moderate, or severe in degree. If it is not feasible to address the functional limitation, this should be stated and discussed in the examination report. If the Veteran does not have pain or any other factors, that fact should be noted as well. 2. Thereafter, the issue of an increased rating in excess of 10 percent as of May 24, 2006 for limitation of motion due to arthritis as a postoperative residual of a right knee injury should be readjudicated. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The Veteran and representative have the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims 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). ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012). Department of Veterans Affairs