Citation Nr: 1321912 Decision Date: 07/09/13 Archive Date: 07/18/13 DOCKET NO. 06-21 091 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for the residuals of right wrist arthroscopy with severely decreased range of motion. 2. Entitlement to a compensable evaluation, for the period prior to June 28, 2012, and in excess of 20 percent disabling, for the period beginning June 28, 2012, for peripheral neuropathy of the right hand. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from July 1982 to July 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. In a subsequent rating decision of November 2005, the RO increased the Veteran's previously-assigned 20 percent evaluation to 30 percent, once again, effective from March 22, 2004, and, in so doing, recharacterized the Veteran's right wrist disability as the residuals of right wrist arthroscopy with severely decreased range of motion. In a decision of April 2011, the Board denied entitlement to an evaluation in excess of 30 percent for the service-connected residuals of right wrist arthroscopy with severely decreased range of motion for the period from March 22, 2004 to June 2, 2009. At that same time, the Board remanded for additional development the issue of entitlement to a current evaluation in excess of 30 percent for the Veteran's service-connected right wrist disability effective from June 3, 2009. In a December 2011 Order, the United States Court of Appeals for Veterans Claims (Court) vacated that portion of the Board's April 2011 decision which denied entitlement to an evaluation in excess of 30 percent for the service-connected residuals of right wrist arthroscopy for the period from March 22, 2004 to June 2, 2009, and, in so doing, remanded the Veteran's case to the Board for action consistent with a November 2011 Joint Motion for Remand. The Veteran did not request, and the Court did not disturb, that portion of the Board's April 2011 decision remanding for additional development the issue of entitlement to a current evaluation in excess of 30 percent for the service-connected residuals of right wrist arthroscopy effective from June 3, 2009. Subsequently, in May 2012 the Board remanded the claims for additional development. As the issues of entitlement to an evaluation in excess of 30 percent for the residuals of right wrist arthropathy with severely decreased range of motion for the period from March 22, 2004 to June 2, 2009, and entitlement to a current evaluation in excess of 30 percent for the residuals of right wrist arthropathy with severely decreased range of motion from June 3, 2009, are both currently before the Board and represent the same issue over two periods of time, the Board has recharacterized the issues as entitlement to an evaluation in excess of 30 percent for the residuals of right wrist arthroscopy with severely decreased range of motion In December 2012 the RO granted entitlement to service connection for peripheral neuropathy, right hand, and assigned a noncompensable evaluation, effective August 1, 2002, and an evaluation of 20 percent disabling, effective June 28, 2012. The Board notes that the November 2011 Joint Motion for Remand, granted by the Court in December 2011, found that the Board had erred in not considering whether the Veteran was entitled to a separate evaluation for his right wrist disability based upon impairment of the hand and cited the Diagnostic Codes for neurological disabilities. As such, the Board finds that the pending claim of entitlement to a higher evaluation for a right wrist disability encompasses the issue of entitlement to a higher evaluation for peripheral neuropathy of the right wrist. Therefore, this issue is before the Board for consideration. It appears that the Veteran has perfected an appeal of entitlement to service connection for arthritis of the left wrist with the submission of a Substantive Appeal on a VA Form 9 dated in September 2009. However, as of yet this issue has not been certified to the Board for appellate review. As this issue may be undergoing additional development, it is currently not ripe for Board consideration. The Court determined that where, as here, a claimant, or the record raises the question of unemployability due to the disability for which an increased rating is sought, then part of the increased rating claim is an implied claim for TDIU. Rice v. Shinseki, 22 Vet. App. 447, 453-455 (2009). In a statement received in April 2013 the Veteran indicated that he sought various employments as his hand worsened and that became unemployed for a period of time due to his right hand disability. The Veteran indicated that he could not perform the duties required of him in three separate jobs and that he had an income of zero in 2008. He further reported that he went back to school and finally got another job in July 2009. The Board has therefore added a TDIU claim to the issues on appeal. Further development is needed to properly adjudicate the TDIU claim. The issue of entitlement to a TDIU 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. During the entire period on appeal limitation of motion of the right wrist akin to that of ankylosis was not demonstrated in any position, even when considering pain and fatigue. 2. Prior to June 3, 2009, the Veteran's peripheral neuropathy of the right hand did not nearly approximate mild incomplete paralysis of the radial nerve. 3. From June 3, 2009, to prior to June 28, 2012, the Veteran's peripheral neuropathy of the right hand most nearly approximated mild incomplete paralysis of the radial nerve. 4. From June 28, 2012, the Veteran's peripheral neuropathy of the right hand most nearly approximates moderate incomplete paralysis of the radial nerve. CONCLUSIONS OF LAW 1. The criteria for the assignment of an evaluation in excess of 30 percent for the residuals of right wrist arthroscopy with severely decreased range of motion have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.40, 4.45, 4.59, 4.71, Diagnostic Codes 5214, 5215 (2012). 2. The criteria for a compensable evaluation for peripheral neuropathy of the right hand, for the period prior to June 3, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.123, 4.124a, Diagnostic Code 8514 (2012). 3. The criteria for a disability rating of 20 percent, and no higher, for peripheral neuropathy of the right hand, for the period beginning June 3, 2009, to prior to June 28, 2012, have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.123, 4.124a, Diagnostic Code 8514. 4. The criteria for an evaluation of 30 percent disabling, and no higher, for peripheral neuropathy of the right hand, for the period beginning June 28, 2012, have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.123, 4.124a, Diagnostic Code 8514. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 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, if any, 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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 in accordance with 38 C.F.R. § 3.159. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In a claim for an increased evaluation, the notice requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the VCAA duty to notify was satisfied by way of a letter sent to the appellant in June 2005 that fully addressed all notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the appellant of what evidence was required to substantiate the claim of entitlement to an evaluation in excess of 30 percent for the residuals of right wrist arthroscopy with severely decreased range of motion and of the appellant's and VA's respective duties for obtaining evidence. Although this notice letter did not provide the Veteran with notice that a disability rating and an effective date for the award of benefits would be assigned if his claim was granted, the Veteran was notified of this in a letter dated in March 2006 and the Veteran's claim was readjudicated in a Statement of the Case thereafter in May 2006. In regard to the claim of entitlement to a compensable evaluation, for the period prior to June 28, 2012, and in excess of 20 percent disabling, for the period beginning June 28, 2012, for peripheral neuropathy of the right hand, the Board notes that the Veteran is essentially challenging the initial evaluation and effective date assigned following the grant of service connection. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, VA's duty to notify in this case has been satisfied. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records. The Veteran submitted records from Upstate Medical University, Lifecare, Strong Health, and Drs. D.M., B.H., J.M., and A.R. The appellant was afforded VA medical examinations in May 2004, September 2005, December 2009, and June 2012. In addition, an opinion was obtained in November 2012 based upon claims file review. In May 2008 the Board remanded the Veteran's claim of entitlement to higher evaluation for a right wrist disability for the Veteran to be requested to identify all medical treatment since September 2005, for all identified treatment records to be obtained following the receipt of any necessary authorization, and for the Veteran to be provided an examination. In May 2008 the Veteran was sent a letter requesting that he identify all providers of treatment since September 2005. The Veteran subsequently identified and provided authorization for VA to obtain treatment records from three providers. The records of the Veteran's treatment by the providers identified were obtained and associated with the claims file. Thereafter, the Veteran was afforded a VA medical examination in December 2009. In April 2011 the Board remanded a portion of the period on appeal so that additional treatment record could be obtained and associated and for the Veteran to be afforded another medical examination. In May 2012, after the period on appeal adjudicated by the Board in April 2011 was vacated for further consideration by the Court,the Board remanded the entire period on appeal for additional treatment records to be obtained and associated with the claims file and for the Veteran to be afforded another medical examination. Subsequently, additional VA treatment records were obtained and associated with the claims file and the Veteran was afforded a VA medical examination in June 2012. An opinion was obtained in November 2012 based upon claims file review. The Board finds that the examinations were adequate to allow proper adjudication of the issues on appeal. The examiners conducted complete examinations, recorded all findings considered relevant under the applicable diagnostic codes, and considered the full history of the disabilities . Therefore, based on the foregoing actions, the Board finds that there has been substantial compliance with the Board's remands. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Higher Evaluation Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; 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; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Residuals of Right Wrist Arthroscopy The Veteran's residuals of a right wrist arthroscopy of the right hand has been rated as 30 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5214. Under that Diagnostic Code, ratings are applied based on whether the disabled extremity is the major or minor extremity. The record shows that the Veteran is right handed; therefore, the Veteran's disability will be evaluated utilizing the ratings applicable to the major extremity. Under the provisions of Diagnostic Code 5214, a 30 percent evaluation is warranted for favorable ankylosis of the major wrist in 20 degrees to 30 degrees dorsiflexion. Ankylosis in any other position than favorable warrants a 40 percent rating for the major wrist and unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation warrants a 50 percent disability evaluation for the major wrist. Limitation of motion of the wrist warrants a 10 percent disability rating where dorsiflexion less than 15 degrees is shown. A 10 percent disability rating is also warranted where palmar flexion limited in line with the forearm is demonstrated. 38 C.F.R. § 4.71a, Diagnostic Code 5215. Standard ranges of motion of the wrist are extension (dorsiflexion) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. In December 2003 the Veteran was noted to report that he had right wrist swelling and that it always felt partly numb. In March 2004, the Veteran submitted a claim for an increased rating for his right wrist disorder, in June 2004, his disability evaluation was increased from 10 to 20 percent disabling and in November 2005 the Veteran's rating was increased from 20 to 30 percent disabling, effective March 22, 2004. In April 2004, Dr. A.R. reported that the Veteran had some problems with stiffness and pain in the wrist and was planning further evaluation at the VA hospital. He was noted be using Bextra with some relief. It bothered him most at work if he was involved in "holds" with the residents. The physician noted that with Bextra his pain was generally controlled and that it had been recommended in the past that the Veteran pursue further surgery. Included in the claims file is a May 2004 VA examination report. During his examination, the Veteran reported flare-ups at least four times a week with pain and swelling due to extra activity. The Veteran stated that he had difficulty holding a cup and writing and that he gave up a lot of activities due to wrist pain. It was noted that the Veteran was able to carry out daily activities without assistance but that his family had to help him perform such chores as mowing the lawn and snow blowing. The examiner noted that he worked as a child care counselor and that he had not missed work recently due to his right wrist. On physical examination, the examiner noted that the Veteran was very protective of his right wrist and held it stiffly and did not make unnecessary movements. There was no deformity, abnormal color, muscle atrophy or crepitus noted, nor was there edema. There was significant pain with motion and decreased grip strength on the right. The Veteran was able to differentiate between pain and light touch. Dorsiflexion was from 0 to 20 degrees and palmar flexion was from 0 to 40 degrees. Ulnar deviation was 15 degrees and radial deviation was 10 degrees. After repetitively flexing and extending, there was no change in pain, weakness, fatigability and incoordination. A diagnosis of degenerative changes of the right wrist, status post arthroscopy was provided. An x-ray examination of the right wrist in May 2004 revealed a normal study of the wrist. The record includes a May 2004 statement from the Veteran's co-worker, J.W., in which he noted that the Veteran was frequently hindered in his day-to-day work duties as a child care supervisor. J.W. further noted that at times the Veteran was not able to type reports, assist in safety holds or carry things needed for his position. He stated that it was clear that the Veteran was unable to perform some of the daily activities that he had once enjoyed. J.W. stated that the Veteran's job allowed him to participate in recreational activities with clients but that the Veteran was often unable to participate due to his wrist disorder. In an August 2004 treatment note from private physician Dr. J.M., it was noted that the Veteran had significant loss of dorsiflexion and loss of some palmar flexion. An impression of chronic right wrist pain, loss of motion and a possible need for fusion was noted. In a private treatment record dated in August 2004 the Veteran was noted to hold his wrist in a fixed position. In March 2005 the Veteran reported that his only option for his right wrist was fusion surgery and that he declined that at that time. He stated that if he writes his hand will quickly cramp up. Physical examination revealed that his right wrist had no swelling, redness, heat, or tenderness. There was moderate decreased range of motion in all directions. The Veteran was assessed with chronic wrist pain. The Veteran was afforded a VA examination in September 2005. During his examination, the Veteran explained that he was unable to twist his wrist. He stated that he was unable to lift with his right wrist and stated that his right hand cramped after writing. He reported that he frequently needed to rest his hand and wrist and manipulate the fingers to relieve the cramping. Complaints were noted to occur with weather change and increased activity. At that time he will take extra ibuprofen. The flare-up will last at least through the day and it limits the activities, although he will continue to work through the pain. The Veteran denied any incapacitating episodes. It was noted that the Veteran worked as a full time supervisor of adolescents, he explained that his pain severely restricted the activities he was able to do, especially recreationally. On physical examination of the right wrist it was noted that there was no deformity or sensory deficit. There was decreased grip strength in comparison to the left hand. Range of motion studies revealed dorsiflexion from 0 to 10 degrees but dorsiflexion could be forced to 20 degrees with resistance due to increase in pain. Palmar flexion was from 10 to 20 degrees at most. Radial deviation was 10 degrees with an increase in pain. Ulnar deviation was 0 to 20 degrees. There was pain noted through all motions. There was no change in range of motion with repetition. A diagnosis of status post right wrist arthroscopy with degenerative changes was provided. In a January 2006 statement in support of his claim, the Veteran asserted his belief that he should be afforded a 40 percent disability rating due to his limited range of motion. In March 2006 the Veteran reported that he was taking ibuprofen every day and acetaminophen every couple of days for his left knee and right wrist pain. The claims file includes an April 2006 letter from the Veteran's co-worker, E.R. In his letter, E.R. stated that he had worked with the Veteran for three years and that he witnessed the Veteran attempting to use a stapler and being unable to do so due to excruciating pain. E.R. noted that the Veteran was concerned about losing his job due to the limitations caused by his wrist disorder and that he avoided situations where he could be observed by the management team as well as meet and greet situations for fear that he would have to shake someone's hand. E.R. additionally noted that the Veteran had to take several pain pills a day. In an April 2006 statement in support of his claim, the Veteran stated that he took two 500 milligram tablets of acetaminophen and 600 milligrams of ibuprofen twice a day to deal with pain and swelling in his right wrist. The Veteran additionally noted that under the among the essential functions of his job was restraining the youth in his care. The Veteran explained that he had a hard time holding a coffee cup, let alone restraining an aggressive 15 to 21 year old. In February 2007 the Veteran was noted to have a history of chronic wrist pain. Over the prior month the Veteran reported that he had been having more pain. He denied any particular injury. He had been using ibuprofen and heat with some relief. Ice was noted to make the condition worse. He did not wear a splint to work. Examination revealed no significant wrist swelling and no erythema. Treatment notes from Dr. D.M. of the University of Rochester Medical Center dated in March 2007 noted the Veteran's complaints of wrist pain since a 2001 injury. X-rays revealed questionable widening of the scapholunate ligament interval on the right and evidence of a wafer procedure of the distal ulna. Physical examination showed tenderness over the scapholunate ligament interval and some tenderness over the triangular fibrocartilage complex and fovea region. The distal or radial ulnar joint (DRUJ) was stable. Neurovascular examination was intact and well healed surgical incisions were noted. Treatment notes from Dr. D.M. dated in May 2007 noted that the Veteran came for an evaluation of wrist pain. A magnetic resonance imaging (MRI) scan showed edema of the scaphoid and what appeared to be an intact scapholunate ligament. Neurovascular exam was intact. It was noted that the Veteran reported a trauma at work three months prior wherein the Veteran fell and suffered a hyperextension injury when he landed on his wrist on the floor. Dr. D.M. noted that this was possibly consistent with the etiology of the Veteran's scaphoid injury. In August 2007 the Veteran underwent arthroscopy of the right wrist with debridement of scapholunate ligament and removal of osteophyte distal ulna. A September 2007 treatment note from Dr. D.M. noted that the Veteran had undergone a wrist arthroscopy and continuation of a wafer procedure. It was noted that the Veteran was doing extremely well and that on physical examination, the Veteran had near full range of motion. The Veteran was afforded a VA medical examination in June 2009. The Veteran complained of pain in the right wrist and that his fingers tended to go numb on occasion. He stated that he has been having difficulty with his wrist ever since an injury in service and that he had had arthroscopy on two different occasions. He stated that he has temporary relief following these procedures but that the pain returns after a short period of time. He did not use any assistive devices and he was noted to be right handed. The Veteran's functional limitations were reported to be fairly severe with regard to the right hand. He was not able to do any lifting, pushing, or pulling with the right hand. He had difficulty traveling in a car. He stated that if he puts his right arm up on the steering wheel his hand will tend to go numb. He had difficulty sleeping due to the discomfort in his wrist and had difficulty writing. He stated that he had daily flare-ups of wrist pain. He reported one episode of incapacitating wrist pain over the prior year. The episode lasted two to three days and he took Advil during that period which seemed to provide relief. Other than the episodes of numbness the Veteran did not seem to have any associated constitutional symptoms associated with his wrist complaints. He had just completed a vocational rehabilitation program but was not working yet. Physical examination revealed that the Veteran had faded scars over the radiodorsal and radiovolar aspect of his right wrist. He had tenderness on palpation of the dorsum and the volar aspect of the wrist at the radial aspect. Range of motion was flexion of 20 degrees, extension of 50 degrees, radial deviation of 20 degrees, and ulnar deviation of 10 degrees. The Veteran complained of wrist pain at these extremes of motion, particularly in the radial aspect of his wrist. His motor strength of the wrist was 3/5 in all planes. His motor strength dropped to 2/5 on repetitive flexion and extension. The examiner noted that there did not seem to be any deformity of the wrist. There was no crepitus palpable on motion of the wrist. There was no evidence of any subluxation, dislocation, or instability of the wrist. Neurological examination of the wrist was normal. There was no evidence of any sensory deficit of the ulnar, radial, or the median nerve distribution. He had a positive Tinel's sign at the wrist. He was able to touch the proximal palmar crease with all of his fingers. His finger adduction and abduction strength was 5/5. He was able to thumb oppose all fingers without any difficulties. Thumb flexion and extension strength was 5/5. Flexor digitorum profundus and sublimis strength was 5/5. His grip strength was 3/5 and repetitive grip strength was 2/5. He had a positive Phalen and Tinel's sign at the wrist. The Veteran's wrist joint range of motion and strength were diminished due to a complaint of pain on attempt at repetitive motion testing, the extent and degree of which was not possible to determine due to the extreme subjectivity of the exercise. The Veteran was diagnosed with advanced degenerative joint disease of the right wrist secondary to wrist injury. The Veteran was afforded a VA medical examination in December 2009. The Veteran continued to complain of right wrist pain with motion. The Veteran did not use any assistive devices. He is right handed. The Veteran reported that he has difficulty lifting, pulling, or pushing. Sitting and traveling in a car was difficult for him. He stated that if he puts his hand up onto the steering wheel his hand tends to go numb. He had difficulty with sleeping and had difficulty with manipulation. He stated that he has daily flare-ups of wrist pain. He had two totally incapacitating episodes of wrist pain over the prior year and these episodes lasted several days. The Veteran complained of episodes of numbness of his right hand. The Veteran was noted to be working for VA. He reported that he lost two prior positions because he was unable to carryout the work that was necessary for those jobs. It was noted that his functional limitations were fairly severe with regard to the right wrist. He reported difficulty writing. Physical examination revealed that the Veteran had faded scars over the dorsal and radial volar aspects of his wrist. There was tenderness of the dorsum and volar aspect of the wrist, the radial aspect. Range of motion was flexion to 20 degrees, extension to 40 degrees, radial deviation to 10 degrees, and ulnar deviation to 30 degrees. The Veteran complained of pain at the extremes of motion, particularly in the radial aspect of his motion. His motor strength was 3/5 in all planes. His motor strength dropped to 2/5 on repetitive flexion and extension. There was no deformity of the wrist. There was no crepitus palpable on motion of the wrist. There was no evidence of any wrist subluxation, dislocation, or instability. Neurological examination of the wrist was normal and there was no evidence of any sensory deficit of the ulnar, radial, or median nerve distribution of the hand. He had a positive Tinel sign at the wrist. He was able to touch the proximal palmar crease with all fingers. His finger adduction and abduction strength was 5/5. He was able to thumb oppose all fingers without difficulty. His thumb flexion and extension strength was 5/5, flexor digitorum profundus and sublimis strength was 5/5. His grip strength was 3/5 and his repetitive grip strength was 2/5. He had a positive Phalen and Tinel's sign at the wrist. Again it was noted that the Veteran's wrist joint range of motion and strength were diminished due to a complaint of pain on attempt at repetitive motion testing, the extent and degree of which was not possible to determine due to the extreme subjectivity of the exercise. Again the Veteran was diagnosed with advanced degenerative joint disease of the right wrist secondary to wrist injury. In June 2012 the Veteran was afforded a VA medical examination. The examiner rendered the opinion that the Veteran has a separate and distinct condition of the right wrist. The Veteran has numbness and tingling in his right wrist hand which is consistent of a nerve neuropathy. This is separate and distinct from his right wrist osteoarthritis. The nerve involvement was noted to be inclusive of the entire period on appeal. The Veteran was noted to be diagnosed with wrist osteoarthritis. He is right hand dominant. He had flare-ups of increased pain and stiffness of the right wrist an average of 7 to 12 times a month lasting on average from 2 to 3 days. The Veteran estimated that he can use his wrist during the flares approximately 20 percent of normal. Range of motion of the right wrist was 35 degrees of palmar flexion with pain beginning at 25 degrees and 40 degrees of dorsiflexion with pain beginning at 30 degrees. The Veteran had 10 degrees of radial deviation and 30 degrees of ulnar deviation. The Veteran was unable to perform repetitive use testing. The Veteran had less movement than normal, pain on movement, and swelling after repetitive use. The Veteran had pain on palpation of the right wrist. Muscle strength was 4/5 for flexion and extension. There was no ankylosis. The Veteran was noted to have had arthroscopic surgery and that he had continued right wrist pain and stiffness following arthroscopic surgery. He had a noticeable arthroscopic portal scar on the right dorsal wrist measuring one and a half centimeter in length by two millimeters. Function was not so diminished that amputation with prosthesis would equally serve the Veteran. Imaging studies revealed degenerative or traumatic arthritis of the right wrist as well as multiple defects at the carpals and there was synovial cyst present and he has had arthroscopy on two occasions and a needle arthroscopy diagnosis was that of advanced degenerative joint disease of the wrist. The Veteran left a manual job in 2006 due to his wrist condition and now had a job that was predominantly desk work. He continued to have limitations with physical labor including limited grip, grab, pushing, and lifting with his right wrist. The Veteran was also provided a peripheral nerves examination. The examiner diagnosed the Veteran with peripheral neuropathy. Symptoms were noted to be moderate intermittent pain, paresthesias and/or dysesthesias, and numbness in the right upper extremity. Muscle strengths were 4/5 for right wrist flexion and extension, and 4/5 for right hand grip and pinch. Reflexes were normal in the biceps, triceps, and brachioradialis. Sensory examination revealed deceased hand/finger sensation. The Veteran had no trophic changes. Tinel's sign was negative on the right. The Veteran was found to have moderate incomplete paralysis of the right radial nerve. The Veteran was noted to use a brace on occasion. Function was not so diminished that amputation with prosthesis would equally serve the Veteran. The Veteran was noted to have a scar but that it was not painful and/or unstable, or greater than 39 square centimeters (6 square inches). In November 2012 the examiner reviewed the Veteran's claims file and rendered the same opinion regarding the Veteran's nerve condition. The Veteran is rated as 30 percent disabled for his right wrist disorder. In November 2005, the RO increased the Veteran's disability rating from 20 to 30 percent citing the Veteran's severely decreased range of motion with associated pain and the limitations of that disorder. The RO stated that the Veteran's disability was not specifically described by the rating schedule and therefore rated the Veteran's disorder by analogy to Diagnostic Code 5214 for ankylosis of the wrist. 38 C.F.R. § 4.20. As demonstrated above, the Veteran's disability is primarily based on his limitation of motion, a disability which is in fact contemplated by the rating schedule under Diagnostic Code 5215, which provides disability ratings for limitation of motion of the wrist. However, the RO applied 38 C.F.R. § 4.20 in rating the Veteran's right wrist disorder in order to allow the possibility of a higher rating. In this regard, the Board notes that the highest available schedular rating for limitation of motion is 10 percent. A rating in excess of 10 percent is not warranted under the code without a showing of favorable or unfavorable ankylosis (which is not shown by any of the evidence). As such, considering the 30 percent rating already afforded to the Veteran, even when taking the DeLuca criteria into account, the Board finds that it has no authority under the present rating criteria to afford the Veteran a higher rating. The claim for an increased disability evaluation is therefore denied. The Board has also considered whether a separate evaluation is warranted for the Veteran's right wrist scar. Such a separate evaluation may only be assigned if there is separate and distinct manifestations from the same injury. During the pendency of this appeal, VA revised the criteria for diagnosing and evaluating the skin, effective October 23, 2008. See 73 Fed. Reg. 54708-12 (Sept. 23, 2008). With regard to the revision made to the skin regulations effective October 23, 2008, the revised criteria apply to all applications for benefits received by VA on or after that date. As the Veteran's claim was received prior to October 23, 2008, the revised criteria are not for application in this case. The amendment allows for a Veteran to request a review of a scar disability under the revised criteria irrespective of whether the Veteran's disability has increased since the last review. Id. However, no such request has been made. Accordingly, the Veteran's right wrist scar will not be considered under the revised criteria effective October 23, 2008. A separate rating for the Veteran's right wrist scar is not warranted in this case, as there is no evidence that the Veteran scar is deep, causes limited motion, exceeded 144 square inches (929 square centimeters), is unstable, is painful on examination, or causes limitation of function. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). Accordingly, a separate evaluation for right wrist scar is not warranted. B. Peripheral Neuropathy of the Right Hand In December 2012 the RO granted entitlement to service connection for peripheral neuropathy, right hand, and assigned a noncompensable evaluation prior to June 28, 2012, and an evaluation of 20 percent disabling, for the period beginning June 28, 2012, pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8514. The Board notes that the Court remanded the Veteran's claim for a higher evaluation for residuals of right wrist arthroscopy with severely decreased range of motion with the instruction to consider whether the Veteran was entitled to a separate compensable evaluation for the neurological manifestations of his wrist disability. As such, the Board finds the evaluation of the neurological component of the Veteran's wrist disability is before the Board on appeal as it represents a component of the Veteran's perfected appeal. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating which may be assigned for neuritis not characterized by organic changes as noted above will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate, incomplete paralysis. 38 C.F.R. § 4.124. Significantly, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or due to partial regeneration. Moreover, when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The provisions of 38 C.F.R. § 4.124a, which apply to the rating of diseases of the peripheral nerves, expressly provide for the application of different rating criteria depending upon whether a Veteran's minor (non-dominant) or major (dominant) side is being evaluated. See 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. In this case, as noted above, the Veteran is right-hand dominant; therefore, the Veteran's disability will be evaluated utilizing the ratings applicable to the major extremity. Diagnostic Code 8514 provides the rating criteria for paralysis of the musculospiral nerve (radial nerve), and therefore neuritis and neuralgia of that nerve. Complete paralysis of that nerve, which is rated as 70 percent disabling for the major arm, is indicated when there is drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. Disability ratings of 20 percent, 30 percent, and 50 percent are assignable for incomplete paralysis which is mild, moderate, or severe in degree, respectively, for the major arm. 38 C.F.R. § 4.124a, Diagnostic Code 8514. Diagnostic Code 8512 provides the rating criteria for paralysis of the lower radicular group, and therefore neuritis and neuralgia of that nerve. Complete paralysis of that nerve, which is rated as 70 percent disabling for the major arm, is indicated when there is paralysis of all intrinsic muscles of hand, and some or all of flexors of wrist and fingers (substantial loss of use of hand). Disability ratings of 20 percent, 40 percent, and 50 percent are assignable for incomplete paralysis which is mild, moderate, or severe in degree, respectively, for the major arm. 38 C.F.R. § 4.124a, Diagnostic Code 8512. As discussed in detail above, the Veteran has complained of right wrist pain during the entire period on appeal. In September 2005 the Veteran was not found to have any sensory deficit. In March 2007 the Veteran was noted to be neurovascularly intact. On June 3, 2009 the Veteran complained of pain in the right wrist and reported that his fingers tended to go numb on occasion. At that time his motor strength was 3/5 in all planes and this dropped to 2/5 on repetitive flexion and extension. However, neurological examination was noted to be normal and there was no sensory deficit. Grip strength was reduced to 3/5 with repetitive grip strength further reduced to 2/5. In June 2012 the Veteran was noted to have numbness and tingling in his right wrist hand that was consistent with a nerve neuropathy. The examiner noted that the nerve involvement was inclusive of the entire period on appeal. Nerves examination revealed moderate intermittent pain, paresthesias and/or dysesthesias, and numbness in the right upper extremity. Muscle strengths were 4/5 for right wrist flexion and extension, and 4/5 for right hand grip and pinch. Reflexes were normal in the biceps, triceps, and brachioradialis. Sensory examination revealed deceased hand/finger sensation. The examiner categorized the Veteran's nerve impairment as moderate incomplete paralysis of the radial nerve. Initially, the Board finds that the nerve involved has been idenitified as the radial nerve. Therefore, the Board finds that the appropriate diagnostic code for application is Diagnostic Code 8514 which encompasses paralysis of the musculospiral nerve (radial nerve). See Butts v. Brown, 5 Vet. App. 532, 538 (1993). The Board finds that the Veteran's peripheral neuropathy of the right hand does not warrant a compensable evaluation prior to June 3, 2009. Prior to June 3, 2009, the Veteran was noted to be neurovascularly intact. As such, entitlement to a compensable evaluation for the period prior to June 3, 2009, is denied. The Board finds that the Veteran's peripheral neuropathy of the right hand warrants an evaluation of 20 percent disabling, and no higher, for the period beginning June 3, 2009, to prior to June 28, 2012. During this period the Veteran's disability manifested numbness, reduced motor strength, and reduced grip strength. However, neurological examination was normal and there was no sensory deficit. The Board finds that the symptoms of the Veteran's peripheral neuropathy beginning June 3, 2009, most nearly approximate mild incomplete paralysis of the radial nerve, and therefore, an evaluation of 20 percent disabling, for the period beginning June 3, 2009, to June 28, 2012, is granted. The Board finds that the Veteran's peripheral neuropathy of the right hand warrants an evaluation of 30 percent disabling, and no higher, for the period beginning June 28, 2012. Beginning June 28, 2012, the Veteran's right hand peripheral neuropathy manifested symptoms of numbness and tingling, moderate intermittent pain, paresthesias and/or dysesthesias, reduced muscle strengths, reduced grip and pinch, and decreased hand/finger sensation. The examiner on June 28, 2012, categorized the Veteran's disability as moderate incomplete paralysis of the radial nerve. However, the Veteran's symptoms were not noted to be severe. As such, entitlement to an evaluation of 30 percent disabling, and no higher, for peripheral neuropathy of the right hand is granted, effective June 28, 2012. C. Extraschedular Consideration The discussion above reflects that the rating criteria reasonably describe and contemplate the severity and symptomatology of the Veteran's service-connected right wrist disabilities. The Veteran's disabilities are manifested by impairment in range of motion, pain, loss of muscle and grip strength, and numbness. The rating criteria contemplate these impairments; hence, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an evaluation in excess of 30 percent for the residuals of right wrist arthroscopy with severely decreased range of motion is denied. Entitlement to a compensable evaluation for the period prior to June 3, 2009, for peripheral neuropathy of the right hand is denied. Entitlement to a 20 percent evaluation, and no higher, for the period beginning June 3, 2009, to prior to June 28, 2012, for peripheral neuropathy of the right hand, is granted subject to the laws governing the grant of monetary benefits. Entitlement to a 30 percent evaluation, and no higher, for the period beginning June 28, 2012, for peripheral neuropathy of the right hand, is granted subject to the laws governing the grant of monetary benefits. REMAND As the evidence of record indicates that the Veteran has employment limitations due to his right wrist disabilities, the Board finds that a claim of entitlement to a TDIU has been raised. Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009). The Court has held that in the case of a claim for a TDIU, the duty to assist requires that VA obtain an examination that includes an opinion on what effect a Veteran's service-connected disability has on his ability to work. Friscia v. Brown, 7 Vet. App. 294, 297 (1994). Although the examinations, as indicated above, provide discussion of the effects the Veteran's right wrist and hand disabilities have on his ability to work, no opinion has been rendered regarding whether the Veteran's service-connected impairments rendered him unemployable at any point during the period on appeal. As such, the Board finds it necessary to afford the Veteran another VA medical examination. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine whether his service-connected disabilities prevented him from securing and following substantially gainful employment for which his education and occupational experience otherwise qualify him at any point in time during the period on appeal, specifically 2008 through July 2009. The claims folder, including this remand, must be sent to the examiner for review; consideration of such should be reflected in the completed examination report or in an addendum. The examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected disabilities would, in combination, preclude him from securing and following substantially gainful employment for which his education and occupational experience otherwise qualify him at any point in time during the period on appeal, specifically in 2008 through July 2009. The examiner must provide reasons for each opinion given. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 2. Thereafter, adjudicate the Veteran's claim of entitlement to a TDIU. If the benefit sought on appeal is not granted, the RO should issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs