Citation Nr: 1321493 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 05-05 649 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to an increased disability rating for service-connected residuals of a right wrist injury with degenerative changes (major), currently evaluated as 20 percent disabling based on muscle injury. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1979 to February 1988. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from an August 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. A hearing was held in February 2007 in Washington, D.C. before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This case was previously remanded by the Board for additional development in April 2007. In September 2008, the Board denied the Veteran's claims of entitlement to an evaluation in excess of 20 percent for service-connected residuals of a right wrist ligament injury with degenerative changes and entitlement to a compensable evaluation for right elbow bursitis with olecranon spur. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2011 Memorandum Decision, the Court affirmed Board's September 2008 decision as to denial of the claim for a compensable evaluation for the Veteran's service-connected right elbow disability and vacated and remanded the Board's decision as to entitlement to a rating in excess of 20 percent for service-connected residuals of a right wrist ligament injury with degenerative changes for proceedings consistent with the April 2011 Memorandum Decision. In February and December 2012, the Board again remanded the claim for entitlement to a rating in excess of 20 percent for service-connected residuals of a right wrist ligament injury with degenerative changes for additional development. The case has since been returned to the Board for further appellate consideration. A review of the Veteran's Virtual VA electronic claims file is significant for additional VA treatment records dating from 2003 to 2013, which were associated with the record prior to the issuance of the most recent supplemental statement of the case in April 2013. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's residuals of a right wrist ligament injury with degenerative changes (major) is manifested by some limited and weakened motion on extension of the right wrist with complaints of pain, swelling, and tenderness; ankylosis of the wrist or severe disability of the muscles arising mainly from external condyle of the humerus is not shown. 2. Since February 27, 2008, the Veteran's residuals of a right wrist ligament injury with degenerative changes (major) is manifested by some limited and weakened motion on flexion of the right wrist with complaints of pain, swelling, and tenderness with limited ulnar and radial deviation; ankylosis of the wrist or moderately severe disability of the muscles arising mainly from internal condyle of the humerus is not shown. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for the veteran's residuals of a right wrist ligament injury with degenerative changes with weakened and limited motion on extension of the right wrist (major) have not been met at any time. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.55, 4.56, 4.73, Diagnostic Code 5308 (2012). 2. After resolving all reasonable doubt in the Veteran's favor, from February 27, 2008, the criteria for a separate 10 percent rating, but not more, for the Veteran's residuals of a right wrist ligament injury with degenerative changes with weakened and limited motion on flexion of the right wrist (major) have been met. 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.55, 4.56, 4.73, Diagnostic Code 5307 (2012). 3. After resolving all reasonable doubt in the Veteran's favor, from February 27, 2008, the criteria for a separate 10 percent rating, but not more, for arthritis of wrist manifested by limited ulnar and radial deviation have been met. 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.55, 4.56, 4.73, Diagnostic Codes 5003, 5010 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As noted above, the Board most recently remanded this matter for further evidentiary development in December 2012. The Board instructed the RO/AMC to (1) obtain the Veteran's current mailing address and update the record accordingly; (2) obtain any relevant private treatment records identified by the Veteran, to include from KP dating from 2006 to 2007; (3) obtain VA treatment records from the Atlanta and Durham VA Medical Centers dating from 2003 to 2009, and since February 2012, and; (4) readjudicate the claim. In December 2012, the AMC obtained the Veteran's current mailing address and updated the record and the AMC requested that the Veteran submit or request VA's assistance in obtaining any outstanding treatment records relevant to his claim, to include the aforementioned private treatment records from KP. In January 2013, authorization was received from the Veteran to obtain the aforementioned private treatment records from KP. Records were requested from KP in March and April 2013, however, a negative response was received from KP in April 2013. The requested VA treatment records were associated with the Veteran's Virtual VA electronic claims file in December 2012 and April 2013. The claim was subsequently and most recently readjudicated in the April 2013 supplemental statement of the case. Thus, there is compliance with the Board's remand instruction. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist In preadjudication correspondence dated in November 2002 and in post-adjudication correspondence dated in May 2007, the RO/AMC satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the letters notified the Veteran of: information and evidence necessary to substantiate his claim for increase; information and evidence that VA would seek to provide; and information and evidence that he was expected to provide. The letters informed the Veteran that in order to establish a higher rating, the evidence would need to show that his disability had increased in severity. The May 2007 letter provided notice of the types of evidence that could be submitted to support his claim for an increased rating. It also provided notice of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claim was last readjudicated in the April 2013 supplemental statement of the case. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Evidence that has been obtained and associated with the claims file includes identified VA and private treatment records, reports of orthopedic and joint evaluations, records obtained from the Social Security Disability Administration, and lay statements and testimony of the Veteran. All identified and available VA and private treatment records have been secured. Additionally, the Veteran was provided with VA examinations to determine the nature and severity of his service-connected right wrist disability in September 2002, February 2008 and March 2012. The aforementioned examination reports reflect that the examiners reviewed and recorded the Veteran's documented and/or reported current and past medical history and current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Further, the combination of the Veteran's testimony, statements, and examination reports documenting function complaints and problems associated with the Veteran's right wrist disability provide a full and accurate picture of the Veteran's disability so as to allow the Board to render an informed decision. Thus, the Board concludes that the evidence of record is adequate for purposes of rendering a decision in the instant appeal and VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Barr, 21 Vet. App. at 312. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. Statements and testimony received from the Veteran and his representative show that they have actual knowledge of the information and evidence necessary to substantiate the claim. As noted, in February 2007, the Veteran was afforded a VA Central Office hearing before the undersigned during which he presented oral argument in support of his claim for an increased rating. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs 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, the VLJ fully explained the issue on appeal during the hearing. Significantly, neither the appellant nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). For the foregoing reasons, the duties to notify and assist have been met and the Board may proceed with adjudication of the claim. 38 C.F.R. § 20.1304(c) (2012). Factual Background In February 2002, the Veteran complained that right wrist pain was so severe that he could not do his work as a painter. Physical examination revealed limited motion on hyperextension and medial movement. X-ray examination of his right wrist showed degenerative joint disease involving the radiocarpal joint with space narrowing, subarticular sclerosis, and marginal spurring from the distal radius and scaphoid. He was medically excused from work for 6 days. In May 2002, there were objective findings in the right wrist of mild swelling and decreased motion on extension and lateral movements. During VA occupational therapy for the right wrist in June 2002, active range of motion was "limited by 50 percent." Pain interfered with the Veteran's work tasks as a painter. A neoprene wrist support was ordered. In September 2002, the Veteran presented for a clothing allowance evaluation pertaining to his use of a right wrist splint with metal stays. The Veteran was afforded a VA QTC examination in September 2002. Right wrist and hand complaints included swelling, which he treated with pain medication and use of a wrist brace. He described an ability to perform all activities of daily living He worked as a painter which had been his usual occupation since 1991. Physical examination of the wrist was grossly within normal limits. There was some tenderness to palpation to the proximal aspect of the wrist. Phalen's and Tinel's signs were negative. The right wrist demonstrated dorsiflexion (extension) limited to 60 degrees, unlimited palmar flexion to 80 degrees with pain at 80 degrees, unlimited radial deviation to 20 degrees with pain, and unlimited ulnar deviation to 45 degrees without pain. There was mild pain on range of motion; however, there was no evidence of fatigue, weakness, lack of endurance, or incoordination. Hand grip strength was normal (5/5). X-ray of the right wrist was indicative of degenerative change of the right radiocarpal joint. The examiner diagnosed degenerative joint disease of the right radiocarpal joint with mild pain on use. The Veteran's right wrist disability was not productive of significant limitations on his normal functioning. During a May 2003 annual assessment, there was mild swelling with decreased range of motion of the right wrist; however, specific motion measurements were not indicated. A new wrist splint was ordered. During an October 2003 orthopedic consultation, the Veteran's wrist was reportedly doing well except for some discomfort on flexion and extension. There were objective findings of decreased motion on flexion and extension due to pain. Sensation to light tough was intact. There was no edema. X-rays of the right wrist were significant for degenerative changes with findings of joint space narrowing at the radioscaphoid joint, hypertrophy of the radial styloid process, deformity of the scaphoid bone, scaphotrapezial osteoarthritis, widening of the scapholunate space, and cystic changes within the lunate bone. In comparison to X-rays dated in February 2002, there were no interval changes of the right wrist. In his July 2004 notice of disagreement and February 2005 VA Form 9 the Veteran indicated that he had to use his left hand as his dominant hand due to his right wrist disability. Private treatment records from KP dated in January 2007 show a complaint of chronic pain and aches from injuries sustained during service, which reportedly had bothered him for years and affected his sleep. In February 2007, the Veteran reported pain from several conditions "(back, leg, shoulder, wrist)," which resulted in physical limitations due to chronic pain. A February 2007 pain management group note showed diagnosis of chronic pain due to torn ligaments in the wrist. In March 2007, it was noted that he Veteran believed that his Central Office hearing went well. Work was going well for him and his overall attitude seemed better. During the February 2007 Central Office hearing, the Veteran testified that he is right hand dominant. He was employed as a painter. Due to his right wrist disability, he started each day using his right hand until it became painful at which time he would switch to use of his left hand. He reported right wrist symptoms of fatigue, continuous pain, and intermittent throbbing throughout the day. Especially during work breaks, his right upper extremity from the elbow to the hand went numb or fell asleep. His job duties included lifting heavy paint cans, which required lifting with the left hand or reducing the paint to smaller, lighter containers. He missed work "on and off" to attend doctors appointments for treatment of his right wrist disability. Functionally, wrist pain interfered with sleep for which he was privately prescribed medication for assistance. He sometimes dropped objects, but not often. He could no longer participate in sports. He denied experiencing any sensation that his wrist joint slipped out of place. He reported conservative treatment for his right upper extremity complaints, mostly through VA, with Motrin 800 for pain and use of a wrist splint and brace which decreased pain, weakness, and fatigue. He also attended private pain management group treatment for coping with pain and he was attempting to train his left hand as his dominant hand. While he admittedly experienced pain in other areas (knees, back, and left shoulder), it had not been problematic and treatment for pain was mainly related to his right upper extremity. He stated that range of motion of his wrist was not too good and strength of his right hand had diminished significantly since his initial injury in 1986. Private treatment records received from the Social Security Administration show that in July 2007, X-ray examination of the right wrist revealed widening of the scapholunate interval with moderately advanced osteoarthritis affecting both carpal rows, and near complete collapse of the radioscaphoid joint. Right wrist findings on subsequent examination in July 2007 included diffuse tenderness, swelling, and synovitis without deformity. Range of motion was dorsiflexion (extension) limited to 45 degrees and palmar flexion limited to 40 degrees. Digits of the right hand retained full range of motion. The Veteran was not interested in surgical treatment or injections as his wrist pain was well controlled with light activity and use of a brace. In February 2008, the Veteran underwent a VA joints examination to determine the nature and severity of his right wrist disability. Right wrist complaints included chronic pain treated with use of a wrist brace and regular and neuropathic pain medications. Flare-ups of right wrist symptoms were not reported. Wrist pain did not impair performance of the Veteran's routine activities. He remained employed as a painter at a post office where he had worked since 15 years prior. He carried out his work without any serious problem although he did report pain with excessive work. No special work accommodations had been made for the Veteran's right wrist disability. During the February 2008 VA examination, the Veteran had no problem dressing or undressing. Physical examination of the right wrist revealed some tenderness and swelling. Range of motion of the right wrist was described as "significantly limited" in comparison with his left wrist. Range of motion was dorsiflexion (extension) limited to 20 degrees on the right and 40 degrees on the left; palmar flexion limited to 30 degrees on the right and 60 degrees on the left; ulnar deviation limited to 15 degrees on the right and 20 degrees on the left, and; radial deviation limited to 15 degrees on the right and 30 degrees on the left. There was no pain on initial range of motion testing. There was pain on repetitive motion; however, there was no additional limitation of motion following repetitive motion due to pain, fatigue, lack of endurance, or incoordination. There was some weakened movement of the right wrist; however, there was no additional associated loss of motion due to weakness on repetitive motion. X-ray of the right wrist revealed some loss of cartilage space in the radial carpal joint and intercarpal joints and small osteophyte at the distal end of the radius. The distal end of the ulnar appeared normal. The examiner noted comment in the 2002 examination report that "the Veteran [had] no significant limitations of normal functioning at [that] time," thus, the examiner opined that the Veteran's right wrist disability had advanced to some extent since examination in 2002; however, he was able to remain employed as a painter as he persisted in that occupation. During VA psychiatry examination in June 2010, the Veteran indicated that his right wrist disability had deteriorated in the last 3 years. He wore a right wrist brace on and off throughout the day. He had not worked since May 2009 when he requested early retirement. Significantly, it was noted that he used a cane due to a work-related injury resulting in a slipped disc in his back for which was in the process of claiming disability. In September 2010, the Veteran complained of chronic pain in multiple areas, however, there was no mention of his right wrist. Hand clumsiness issues were denied. During mental health evaluation in November 2010, the Veteran felt truly frustrated by the fact that his physician saw him as physically able to work. Significantly, upon voicing his disagreement, he referred to knee and back problems and indicated that he retired early due to debilitating chronic pain. During a November 2010 VA physical medicine and rehabilitation consultation, radiation of neck pain to the upper extremities was denied; however, the Veteran reported increased numbness and tingling in his fingertips bilaterally. He also reportedly dropped objects off and on. Diagnostic assessment was neck pain and numbness in the bilateral fingertips with MRI cervical spine findings of significant degenerative changes. During a subsequent orthopedic spine evaluation, there was decreased muscle strength (4+/5) of the left upper extremity and diminished sensation to pin prick of the bilateral fingertips. A December 2010 occupational therapy consultation showed treatment for radiculopathy due to complaints of tingling in the hands and radiology reports significant for multilevel degenerative changes in the cervical spine with areas of cord impingement. The upper extremities demonstrated normal strength, sensation, and active range of motion. A February 2011 disability determination of the SSA shows that the Veteran was found to be disabled by that agency effective May 15, 2009, due to a primary diagnosis of a back disorder and a secondary diagnosis of an affective/mood disorder. The SSA decision granting disability benefits was based, in part, on findings of multiple severe orthopedic, psychiatric, and medical impairments, to include a right wrist ligament injury with chronic pain. During a July 2011 occupational therapy consultation for splinting of the right wrist due to pain with numbness and tingling at times, it was found that sensation to light touch was intact. The Veteran was issued a wrist cock up brace to wear while sleeping and a carpal tunnel glove to wear during the day. In October 2011, at the Veteran's request, a VA physicians assistant provided a letter stating that the Veteran had not been gainfully employed for some time and due his long standing diagnosis of major depression it was doubtful that he could be gainfully employed. A December 2011 primary care note shows that the Veteran's chronic pain had not changed or become worse. Prior diagnosis with type II diabetes in 2003 was noted with reports of "burning" and "tingling" in the bilateral fingertips since three years prior. Physical evaluation of the extremities showed that strength was normal, active and passive range of motion was full, and sensation was grossly intact. The Veteran was afforded an additional VA examination to determine the nature and severity of his service-connected right wrist disability in March 2012. He had diagnoses of an intracarpal ligament injury and degenerative joint disease with residual limitation of motion. Right wrist complaints included chronic pain; limited motion of the right wrist; weakness in the right hand; difficulty holding objects in his right hand such as a brush and roller while painting, and; limited ability to lift and carry objects in his right hand. Flare-ups impacting wrist function were not reported. The Veteran's usual occupation was a custodian and painter; however, he had not worked since 2009. Examination of the right wrist during the March 2012 VA examination was significant for findings of localized tenderness or pain on palpation over the dorsum, decreased grip strength (4/5), and decreased strength on active flexion and extension against some resistance (4/5). Examination of the right wrist was negative for evidence of ankylosis, swelling, and history of joint replacement or other surgical treatment. Range of motion of the interphalangeal and metacarpal phalangeal joints was normal. Range of motion of the right wrist was palmar flexion limited to 30 degrees and dorsiflexion (extension) limited to 20 degrees with end of range pain. There was no additional limitation of motion following repetitive-use testing or functional loss and/or functional impairment due to fatigue, lack of endurance, or incoordination. Findings on X-ray examination were suggestive of prior radial styloid fracture with extension into the radiocarpal joint, moderate radiocarpal degenerative joint disease with large radial loose body, proximal migration of the capitates, and mild degenerative changes about the triscaphe joint. The examiner diagnosed moderate posttraumatic radiocarpal degenerative joint disease, which he opined is at least as likely as not secondary to the Veteran's in-service right wrist trauma. The examiner also clarified that radiological finding of "prior radial styloid fracture with extension into the radiocarpal joint" is a new finding that had not been reported on prior arthrograms of the right wrist in 1994, 2002, or 2008. The March 2012 VA examiner characterized the Veteran's right wrist disability as moderate in severity and indicated that that it impacts the Veteran's ability to perform physical work due to an inability to lift and carry more than 10 pounds with his right hand; difficulty gripping and holding objects in his right hand, and; difficulty with repetitive motion of the right wrist during painting. His right wrist disability impacted his ability to perform sedentary employment due to difficulty writing with his right hand for a prolonged period of time. The examiner further clarified that the Veteran's right wrist disability arises from or is the result of muscular impairment as demonstrated by examination findings of decreased strength (4/5) on flexion and extension of the right wrist and right hand grip. Muscles involved in flexion of the wrist include the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus. Muscles involved in extension of the wrist include the extensor carpi radialis longus, radialis brevis, and extensor carpi ulnaris. During a VA occupational therapy consultation in July 2012, the Veteran complained of pain on any movement of his right wrist. Examination revealed pain in the dorsal wrist and ulnar styloid with certain movements. He reportedly required modified independence to complete his daily activities such as washing up or grabbing or picking up items. He would start with use of his right hand and switch to use of his left hand. Significantly, it was noted that the Veteran's neck problems may cause or contribute to bilateral hand numbness and tingling, greater in the right hand. Examination revealed moderate incoordination of the right hand and decreased grip strength. He was issued a prefabricated right wrist cock up brace, a bath mitt with a pocket, and an order was placed for a right carpal tunnel glove. Legal Criteria - Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 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 may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). The evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2012). A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of section 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). Analysis Historically, the Veteran's service-connected residuals of a right wrist injury with degenerative changes (major) have been evaluated under 38 C.F.R. §§ 4.71(a), 4.73, DC 5010-5308, which is reflective of arthritis due to trauma rated as a moderately severe disability of Muscle Group VIII. 38 C.F.R. § 4.27. The Veteran and his representative essentially contend that the single 20 percent evaluation currently assigned for the Veteran's service-connected residuals of a right wrist injury with degenerative changes (major) under DC 5308 for injury to Muscle Group VIII does not adequately compensate the Veteran for the many separate and distinct residual disabilities of his right wrist. Specifically, it is contended that pain, weakness, arthritis, four separate distinct limitations of motion of the wrist, and objective findings of pain and weakness are not contemplated by the 20 percent evaluation currently assigned under DC 5308 for moderately severe injury to Muscle Group VIII. Accordingly, they contend that assignment of one or more separate evaluations is warranted under DC 5010 (traumatic arthritis), DC 5214 (limitation of motion of the wrist), and/or DC 5307 (injury to Muscle Group VII). As noted above, in an April 2011 Memorandum Decision, the Court vacated and remanded the Board's September 2008 decision, which denied the Veteran's claim for a rating in excess of 20 percent for service-connected residuals of a right wrist injury with degenerative changes, so that the Board may reconsider its analysis in accordance with the Court's holding in Esteban, which considers whether under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. Esteban v. Brown, 6. Vet. App. 259, 262 (1994). Specifically, Court found that the Board erred in failing to consider whether the four directions of limited movement in the Veteran's right wrist entitle him to four distinct disability ratings in addition to the 20 percent disability rating currently in effect under 38 C.F.R. § 4.73, DC 5308, which contemplates disability due to injury of Muscle Group VIII. In doing so, the Court cited its holding in Esteban and stated that "[t]he critical element is that none of the symptomatology for any condition is duplicative of or overlapping with symptomatology of the other . . . conditions." Esteban v. Brown, 6. Vet. App. 259, 262 (1994). In this case, the Court observed that Plate I of 38 C.F.R. § 4.71, which portrays measurements of ankylosis and joint motion, shows four different and distinct potential limitations of motion of the wrist, including dorsiflexion (extension), palmar flexion, ulnar deviation, and radial deviation. Accordingly, the Court determined that the Veteran is entitled to separate ratings for each of the limitations of movement in his wrist as symptoms of limited motion of the wrist in four separate directions is distinct and separate and not duplicative or overlapping. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court reasoned that even if the four distinct movements indicated in Plate I are not considered to be four distinct movements indicative of separate symptoms of disability, DC 5307, which contemplates disability of Muscle Group VII, clearly contemplates a disability rating for flexion of the wrist, a movement distinct from extension of the wrist, as contemplated in DC 5038. Moreover, DC 5215, which contemplates disability musculoskeletal system based on limitation of motion of the wrist, appears to provide two separate ratings for both limitation of dorsiflexion (extension) and palmar flexion. Accordingly, the Court concluded that limitation of motion of the wrist in any direction does not constitute one symptom pursuant to DC 5308 and the assignment of multiple evaluations for each direction of limitation of motion of the wrist does not constitute impermissible pyramiding under 38 C.F.R. § 4.14. The Court also found that the Board erred in concluding that that DC 5215 for limitation of motion of the wrist is inapplicable in this case as the 20 percent evaluation currently assigned under DC 5308 is in excess of the maximum 10 percent disability rating available under DC 5215 and it is based on symptomatology that includes limitation of motion. Specifically, the Board failed to explain why the Veteran is entitled to one rating based on one limitation of motion, particularly where the diagnostic code contemplates four potential distinct limitations of motion of the wrist. Accordingly, the Court vacated the September 2008 Board Decision as to the denial of an increased rating for the Veteran's right wrist disability and remanded the claim for further proceedings consistent with the April 2011 Memorandum Decision. DC 5308 is found in the Schedule of Ratings for Muscle Injuries. 38 C.F.R. § 4.73. Diagnostic Code 5308 addresses injuries to Muscle Group VIII, which affects functions of extension of the wrist, fingers and thumb, and abduction of the thumb. The affected muscles arise mainly from the external condyle of the humerus and include the extensors of the carpus, fingers, and thumb, and the supinator. When the dominant extremity is involved, as is the case here, a non-compensable evaluation is assigned when the injury to these muscles is slight, a 10 percent evaluation is assigned when the injury is moderate, a 20 percent evaluation is assigned when the injury is moderately severe, and a 30 percent evaluation is assigned when the injury is severe. Id. In light of the Court's April 2011 Memorandum Decision, it is also significant to note that Diagnostic Code 5307 addresses injuries to Muscle Group VII, which affects functions of flexion of the wrist and fingers and includes muscles arising from the internal condyle of the humerus: flexors of the carpus and long flexors of the fingers and thumb; pronator. When the dominant extremity is involved, as is the case here, a non-compensable evaluation is assigned when the injury to this muscle is slight, a 10 percent evaluation is assigned when the injury is moderate, a 30 percent evaluation is assigned when the injury is moderately severe, and a 40 percent evaluation is assigned when the injury is severe. Id. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-weakness, impaired coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). Evaluation of muscle injuries as slight, moderate, moderately severe, or severe is based on the type of injury, the history and complaints of the injury, and objective findings. 38 C.F.R. § 4.56(d). The Court, citing Robertson v. Brown, 5 Vet. App. 70 (1993), held that 38 C.F.R. § 4.56(d) is essentially a totality-of-the-circumstances test and that no single factor is per se controlling. Tropf v. Nicholson, 20 Vet. App. 317 (2006). Regulations provide that an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). Moreover, a through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). A moderate disability of the muscles may result from through-and-through or deep penetrating wounds of relatively short track by a single bullet or small shell or shrapnel fragment. The absence of the explosive effect of a high velocity missile and of residuals of debridement or of prolonged infection also reflects moderate injury. The history of the disability should be considered, including evidence of hospitalization for treatment of the wound. Consistent complaints on record from the first examination forward of one or more of the cardinal symptoms of muscle wounds, particularly fatigue and fatigue-pain after moderate use, and an effect on the particular functions controlled by the injured muscles should be noted. Evidence of moderate disability includes entrance and (if present) exit scars which are linear or relatively small and so situated as to indicate relatively short track of missile through muscle tissue, signs of moderate loss of deep fascia or muscle substance or impairment of muscle tonus, and of definite weakness or failure in comparative tests. Id. A moderately severe disability of the muscles is characterized by evidence of a through-and-through or deep penetrating wound by a high velocity missile of small size or a large missile of low velocity, with debridement or with prolonged infection, or with sloughing of soft parts, or intermuscular cicatrization. Service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade should be considered. Records in the file of consistent complaints of cardinal symptoms of muscle wounds should also be noted. Evidence of unemployability due to an inability to keep up with work requirements may be considered. Objective findings should include relatively large entrance and (if present) exit scars so situated as to indicate the track of a missile through important muscle groups. Indications on palpation of moderate loss of deep fascia, or moderate loss of muscle substance or moderate loss of normal firm resistance of muscles compared with the sound side may be considered. Tests of strength and endurance of the muscle groups involved may also give evidence of marked or moderately severe loss. Id. A severe disability of the muscles is characterized by evidence of through-and-through or deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or explosive effect of a high velocity missile, or shattering bone fracture with extensive debridement or prolonged infection and sloughing of soft parts, intermuscular binding and cicatrization. Service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade should be considered. Records in the file of consistent complaints of cardinal symptoms of muscle wounds should also be noted. Evidence of unemployability due to an inability to keep up with work requirements may be considered. Id. Objective evidence of severe disability includes extensive ragged, depressed, and adherent scars of skin so situated as to indicate wide damage to muscle groups in the track of a missile. Palpation shows moderate or extensive loss of deep fascia or of muscle substance or soft or flabby muscles in wound area. Muscles do not swell and harden normally in contraction. Tests of strength or endurance compared with the sound side or of coordinated movements show positive evidence of severe impairment of function. Id. If present, the following are also signs of severe muscle damage: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (B) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum, or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. Id. Regulation also provides that a muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. For compensable muscle group injuries that are in the same anatomical region but do not act on the same joint, the evaluations for the most severely injured muscle group will be increased by one level and used as the combined evaluation for the affected muscle groups. The combined evaluation of muscle groups acting upon a single unankylosed joint must be lower than the evaluation for unfavorable ankylosis of that joint, except in case of Muscle Groups I and II acting on the shoulder. 38 C.F.R. § 4.55. On review, the Board finds that the currently assigned 20 percent evaluation assigned under DC 5308 for moderately severe disability of Muscle Group VIII of the dominant right wrist adequately reflects the level of disability warranted under this DC. Neither the Veteran nor his representative have explicitly claimed, not does the evidence otherwise suggest, that the Veteran experiences severe disability of Muscle Group VIII. Rather, they claim that the 20 percent evaluation assigned under DC 5308 does not adequately compensate the Veteran's multiple residual right wrist disabilities, thus, the assignment of additional disability ratings under other relevant diagnostic codes is warranted. In any event, evidence of the Veteran's initial right wrist injury and objective medical findings dating since the claim for increase was received in 2002 cannot be said to be representative of a severe disability due to injury of Muscle Group VIII necessary to warrant the assignment of the next-higher and maximum available evaluation of 30 percent under DC 5308. Initially, the Veteran's current right wrist disability was not diagnosed during service but was found to be related to in-service injury of his right upper extremity when a medical chest fell on him. Wrist complaints did not appear until approximately 5 years following the Veteran's discharge from service. Subsequent incidental in-service X-ray findings showed a well defined bony shadow adjacent to the ulnar epicondyle of the right humerus, which was noted to "possibly" resemble an old trauma. In October 2000, an independent medical examiner opined that X-ray findings indicated separation of the scaphoid and lunate and subsequent development of relatively mild degenerative changes. He diagnosed an old ligamentous injury with subsequent osteoarthritis. He concluded that current wrist symptoms and disability were related to the described in-service injury given that type of injury is difficult to diagnose in early stages and is frequently missed by the initial treating physician. He stated that it takes several years to undergo secondary changes that make the original injury obvious. Accordingly, the initial muscle injury does not appear to be excessively traumatic or reflective of factors indicative of severe muscle injury. Moreover, objective findings of the right wrist and hand since 2002 are not representative of a finding of severe disability due to injury to Muscle Group VIII. Specifically, there are no extensive ragged, depressed, and adherent scars of skin so situated as to indicate wide damage to muscle groups in the track of a missile. Palpation did not show moderate or extensive loss of deep fascia or of muscle substance or soft or flabby muscles in wound area. Although there were findings of some incoordination of the right hand and some weakness evaluated as 4/5, such findings have never been described as severe. Also, while disability of the right wrist due to injury to Muscle Group VIII undoubtedly had adverse effects on the Veteran's usual occupation as a painter until May 2009, private treatment records show that the Veteran refused evaluation for surgical treatment of his right wrist because he reportedly received adequate relief from splinting and pain medication. VA and private treatment records dated in March and April 2009 also show that the Veteran's employment ended in May 2009 upon seeking early retirement immediately after he expressed fear of losing his job due to a second drug-related incident which resulted in his employer's employee assistance program mandating substance abuse treatment. Moreover, while the Veteran missed work to attend medical appointments related to evaluation and treatment of his right wrist disability, and a medical work excuse was provided on one occasion in February 2002, VA treatment records show that he received medical work excuses on more than one occasion for orthopedic disability of his back and lower extremities and he has repeatedly related his inability to work since May 2009 to non service-connected orthopedic disability of his back, neck, and lower extremities. Indeed, days prior to his early retirement in May 2009, he sought a medical work excuse due to low back and lower extremity problems. Accordingly, a preponderance of the evidence shows that the muscle injury disability of Muscle Group VIII is most appropriately characterized as moderately severe at worst and the next-higher 30 percent evaluation for severe disability due to injury of Muscle Group VIII is not warranted at any time under DC 5308. As for consideration as to whether an additional disability rating may be assigned under DC 5307, which addresses separate and distinct functions and symptoms of flexion of the wrist and fingers, the Board notes that objective findings of decreased flexion of the wrist were initially noted during orthopedic consultation on October 17, 2003. However, the March 2012 VA examiner indicated that evidence of right wrist disability due to muscle injury was evidenced by a finding of decreased motor strength on flexion, extension, and hand grip. Using the criteria provided by the examiner, the Board notes that initial objective findings of decreased motor strength of the right hand and wrist were first shown during examination on February 27, 2008. Accordingly, the Board finds that after resolving any doubt in the Veteran's favor, the assignment of an additional disability under DC 5307 effective February 27, 2008 is warranted. Given that disability of right wrist has been most recently described as moderate in severity during VA examination in March 2012, and findings of decreased muscle strength on flexion of the right wrist have only been documented intermittently since initially documented during VA examination on February 27, 2008, the Board finds that objective findings since that time are most consistent with a findings of moderate disability at worst due to injury of Muscle Group VII. Thus, assignment of an additional 10 percent evaluation for moderate disability due to injury of Muscle Group VII in the dominant right hand is warranted effective February 27, 2008. In this regard, as noted above, regulation provides that the combined evaluation of muscle groups acting upon a single unankylosed joint, such as the wrist in this case, must be lower than the evaluation for unfavorable ankylosis of that joint, except in case of Muscle Groups I and II acting on the shoulder. 38 C.F.R. § 4.55. Unfavorable ankylosis of the dominant wrist in any degree of palmar flexion, or with ulnar or radial deviation warrants a 50 percent evaluation. 38 C.F.R. § 4.71a, DC 5214. Thus, a combined 30 percent evaluation resulting from combination of the additional 10 percent disability rating assigned herein for disability due to moderate injury to Muscle Group VII of the dominant wrist and the 20 percent disability rating previously assigned under DC 5308 for moderately severe injury to Muscle Group VIII, which is confirmed and continued herein, is lower than the 50 percent evaluation for unfavorable ankylosis of the major wrist. The Board has also considered whether an additional rating may be assigned under DC 5215 for limitation of motion of the wrist; however, the evidence does not show that assignment of an additional disability rating is warranted for the Veteran's right wrist disability under this diagnostic code. Initially, the Board notes that dorsiflexion (extension) of the Veteran's right wrist has not been shown to be limited to less than 15 degrees at any time as is required to warrant the assignment of a n additional 10 percent disability rating under DC 5215 on the basis of limitation of dorsiflexion (extension) of the right wrist. Similarly, palmar flexion has not been shown at any time to be limited in line with the forearm as required to warrant the assignment of an additional 10 percent disability rating under DC 5215 on the basis of limitation of limitation of palmar flexion. Moreover, as discussed above, limited motion on dorsiflexion (extension) of the Veteran's right wrist is the same symptom used for assignment of the 20 percent disability rating currently in effect under DC 5308, which explicitly contemplates disability due to injury of the muscles that function to extend the wrist. Similarly, limited motion on palmar flexion of the wrist is the same symptom used for assignment of the 10 percent disability rating assigned herein under DC 5307, which explicitly contemplates disability due to injury of the muscles that function to flex the wrist. The Board observes that Plate I also references additional planes of motion (ulnar and radial deviation) of the wrist. The September 2002 examination report shows that the Veteran had normal range of ulnar and radial deviation. The record first shows limitation of such motion during the February 27, 2008 VA examination that revealed limited range of ulnar and radial deviation to 15 degrees. Diagnostic Code 5010 addresses arthritis due to trauma, substantiated by X-ray findings, which is to be rated as degenerative arthritis under DC 5003. See 38 C.F.R. § 4.71a, DC 5010 (2012). Degenerative arthritis, when established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. For the purpose of rating a disability from arthritis, the wrist is considered a major joint. Multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities . . . is considered a group of minor joints ratable on parity with major joints. In this case, while the Veteran has been diagnosed with arthritis of the right wrist, because he is in receipt of compensable ratings under diagnostic codes that contemplate limitation of range of motion (5307 - flexion) (5308 - extension) he is not entitled to a separate 10 percent rating under either DC 5003 or 5010 for limitation of dorsiflexion or palmar flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. Nevertheless, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). As February 27, 2008 VA examination shows that he has limitation of ulnar and radial deviation to 15 degrees and the Court has instructed the Board to consider all plans of motion contained in Plate I, the Board concludes that, a separate 10 percent disability evaluation is warranted for arthritis of the wrist resulting in limitation of ulnar and radial deviation effective February 27, 2008. A rating in excess of 10 percent is not warranted as the record does not show the involvement of more than one major joint or minor joint group. In summary, as demonstrated by the evidence outlined above, and after resolving all doubt in the Veteran's favor, the Board finds that the preponderance of the evidence demonstrates that the criteria for a 20 percent, but no greater, for limitation of dorsiflexion (extension); 10 percent, but no greater, for limitation of palmar flexion (flexion) effective February 27, 2008; and 10 percent, but no greater, for arthritis (ulnar and radial deviation) effective February 27, 2008 are have been met. Extraschedular Consideration In addition, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis for service-connected residuals of a right wrist injury with degenerative changes (major). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In Thun v. Peake, the Court set forth a three-step inquiry to determine a veteran's entitlement to an extra-schedular rating. 22 Vet. App. 111 (2008). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. In this case, it is not necessary to go any further than the first step of the Thun analysis. The rating criteria are not inadequate. Higher ratings are available for more serious manifestations of the Veteran's disabilities considered herein, but the Veteran does not meet those criteria. It does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplate by the schedular criteria. Moreover, the Board has granted an additional 10 percent evaluation for flexion of the wrist and 10 percent for arthritis manifested by ulnar and radial deviation of the wrist which was first shown during VA examination in February 2008. The available schedular evaluations for his service-connected residuals of a right wrist injury with degenerative changes (major) are adequate. The Veteran's disability picture is contemplated by the rating schedule and no extra-schedular referral is required. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Finally, the Board also notes that the Court has held that the issue of a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when a request for TDIU is reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In the instant case, however, the Veteran has not explicitly raised the issue of TDIU. Likewise, the record does not reasonably raise the issue of TDIU. Indeed, a review of the record reveals that he has not worked since May 2009 related to nonservice-connected orthopedic disability and two drug related offences at his place of employment prior to his retirement. Moreover, during the most recent March 2012 examination, the examiner found that the only difficulty his right wrist disability would present in less physically strenuous employment would be difficulty writing with his right hand for long periods. In light of the foregoing, the Board finds that entitlement to TDIU has not been raised. ORDER Entitlement to a disability rating in excess of 20 percent for service-connected residuals of a right wrist injury (Muscle Group VIII) with degenerative changes is denied. Entitlement to an additional 10 percent evaluation for moderate injury of Muscle Group VII effective February 27, 2008 is granted. Entitlement to an additional 10 percent evaluation for arthritis with limitation of ulnar and radial deviation effective February 27, 2008 is granted. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs