Citation Nr: 1323143 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 07-40 036 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to an initial disability evaluation greater than 10 percent for right knee patellofemoral pain syndrome. 2. Entitlement to an initial disability evaluation greater than 10 percent for left knee patellofemoral pain syndrome. 3. Entitlement to an initial disability evaluation greater than 10 percent for carpal tunnel syndrome of the right wrist. 4. Entitlement to an initial disability evaluation greater than 10 percent for carpal tunnel syndrome of the left wrist. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1987 to October 1998, from February 2003 to April 2003, and from December 2005 to February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision of the Department of Veterans Affairs Regional Office in Salt Lake City, Utah. The Veteran testified before the undersigned Veterans Law Judge in a February 2010 videoconference hearing, a transcript of which is included in the record. In March 2012, the Board remanded this matter to the RO via the AMC for adjudication by the RO. The matter has properly been returned to the Board for appellate consideration and the Board is satisfied there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The Veteran submitted additional evidence in June 2012 consisting of VA treatment records from January to April 2012 and waived consideration of the evidence by the RO. In an April 2013 letter the Veteran requested the Disabled American Veterans be removed as his representative, a request he confirmed in writing in May 2013 in response to a letter from the Board. Therefore, the Veteran is now considered to be representing himself. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The issue of entitlement to an increased rating for right knee patellofemoral pain syndrome 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. The Veteran's left knee patellofemoral pain syndrome has been manifest by 0 degrees extension and no less than 78 degrees flexion with pain but no lateral instability. 2. Prior to February 12, 2010, the Veteran's bilateral carpal tunnel syndrome was manifest by only sensory impairment, including intermittent flare-ups of pain and numbness with activity. 3. As of February 12, 2010, the Veteran's bilateral carpal tunnel syndrome was manifest by daily numbness, pain and weakened grip particularly with activity, and infrequent thumb locking and spasming. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for left knee patellofemoral pain syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Code 5024, 5256-5263 (2012). 2. The criteria for an initial rating in excess of 10 percent for left and right carpal tunnel syndrome have not been met prior to February 12, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). 3. The criteria for a 30 percent rating, but no higher, for the Veteran's right carpal tunnel syndrome, and 20 percent rating, but no higher, for the Veteran's left carpal tunnel syndrome, have been met as of February 12, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2012). If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). Left Knee Patellofemoral Pain Syndrome The Veteran's patellofemoral pain syndrome is rated under Diagnostic Code 5260-5024. Diagnostic Code 5024 is for tenosynovitis and is rated on limitation of motion of the affected part. 38 C.F.R. § 4.71a. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a 10 percent rating where flexion is limited to 45 degrees, 20 percent rating where flexion is limited to 30 degrees, and 30 percent rating where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DCs 5260. Diagnostic Code 5261 provides for a 10 percent rating where extension is limited to 10 degrees, 20 percent rating where extension is limited to 15 degrees, 30 percent rating where extension is limited to 20 degrees, 40 percent rating where extension is limited to 30 degrees, and 50 percent rating where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court of Appeals for Veterans Claims held that diagnostic codes that provide a rating solely on the basis of loss of range of motion must be considered with 38 C.F.R. §§ 4.40 and 4.45 (regulations pertaining to functional loss due to pain, etc.). Therefore, to the extent possible, the degree of additional range of motion loss due to pain, weakened movement, excess fatigability, or incoordination should be noted. However, when the maximum rating for limitation of motion of a joint has already been assigned, a finding of pain on motion cannot result in a higher rating. Johnson v. Brown, 9 Vet. App. 7 (1997). The knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). Additional diagnostic codes also apply to rating knee disabilities. 38 C.F.R. § 4.71a. Under Diagnostic Code 5257, a 10 percent evaluation is granted for recurrent subluxation or lateral instability of the knee that is slight. A 20 percent evaluation is granted when there is moderate subluxation or lateral instability of the knee. Diagnostic Code 5258 applies where the semilunar cartilage is dislocated with frequent episodes of "locking," pain, and effusion into the joint. The Veteran was afforded a VA examination in August 2006. He reported constant right knee pain at a 3 out of 10 with flare-ups at 6 out of 10 that decrease to 2 out of 10 with aspirin. He reported running, walking, or jarring activity causes the pain to flare up and his knee has given out once. He stated that his left knee only had pain on flare-ups. The examiner measured his range of motion on the right to 0 degrees extension and 125 degrees flexion, with pain at the end and on the left to 0 degrees extension and 130 degrees flexion, with pain at the end. With repetitive motion there was no increase in fatigue, decreased range of motion, increased pain, weakness, or incoordination. X-rays were normal, providing some evidence against this claim. In a statement dated May 2007 the Veteran stated that his knee condition had gotten worse, making it hard to walk up and down stairs and almost impossible to run. He also stated the popping had gotten worse. The Veteran was afforded a VA examination in August 2007. He reported his knees were a 3 out of 10 for pain while sitting and the pain increases to 6 out of 10 with walking and 8-9 out of ten with stairs or incline. He reported regular clicking and popping and a feeling of grinding, but no locking or falling. His knees demonstrated extension to 0 degrees bilaterally with pain throughout that motion and flexion to 90 degrees on the right and 78 degrees on the left with pain at the end of each motion. The examiner stated that based on a limited exam the Veteran's knees appeared stable. His valgus varus was intact for stability. A statement by the Veteran's wife submitted in August 2007 related that activities including mowing the lawn and going hiking cause the Veteran knee pain. The Veteran underwent another VA examination in January 2009. He reported daily pain at 4 out of 10 in severity, with flare-ups twice a day to 9 out of 10 for 15 minutes to two hours, with Motrin providing some relief. He reported a flare-up decreased his range of motion by 30 percent and was manifest by weakness, fatigue, and incoordination. He reported using an elastic brace only on the left knee, which had given way 3 to 4 times. He did not report any instability of the right knee. He reported that neither knee locks. His bilateral knee flexion was measured to 110 degrees with pain from 80 degrees on the right and from 60 degrees on the left. Extension was measured at 0 degrees with pain at 0 degrees bilaterally. Repetitive motion did not change his symptoms on the right but increased his pain on the left. Strength and sensation were normal in the lower extremities and both joints were stable. He had crepitus and tenderness over the lateral joint line on the left. Varus, valgus, anterior, and posterior drawer and McMurray were all normal. In a March 2009 statement the Veteran said the pain in his knees had gotten more intense and his knees had collapsed on several occasions. In June 2009 the Veteran reported to his private physician that he gets a stabbing, hot pain under his knee cap when climbing stairs. He stated that pain only comes with activity and last about 20 minutes. He reported buckling and occasional instability. The doctor found no effusion, full range of motion, some crepitation of the patella femoral joint, and a little pain to deep pressure. X-rays showed no significant degenerative changes. In July 2009 he was seen at the VA orthopedic clinic where he reported having achy pain in the morning and then some pain with activities and stairs. He reported no instability events, but stated sometimes his knee will give way a little bit secondary to pain when he is ambulating on stairs. He reported no locking or mechanical symptoms. On examination, the doctor found his knee to be stables to anterior, posterior, and varus and valgus stressing. No significant pain was noted with patellar compression and no patellar apprehension. The doctor stated that the most likely diagnosis was patellofemoral syndrome and the Veteran has no evidence of instability or meniscal pathology. The Veteran attended eight physical therapy visits and returned to the orthopedic clinic in September 2009. He reported his knee pain is primarily anterior and feels like a hot needle under his knee caps. He said he feels like his knee will give out about once a week and locks once every two weeks. The doctor measured the Veteran's knee flexion to 140 degrees with normal extension bilaterally. At a follow-up appointment at the orthopedic clinic in March 2010 the Veteran reported he had been doing ok overall but had noticed more lateral-sided knee pain. No mechanical symptoms or knee instability was noted. He was found to have flexion to 130 degrees and a negative McMurray. X-rays showed overall normal bony alignment. At his February 2010 Board hearing, the Veteran testified that he had been experiencing lateral instability in both knees and that his knees had buckled or given out approximately five times in the previous year. He testified that he wears braces on both knees, and that on one or two occasions his knee had locked up for 20 to 30 minutes during which time he was unable to move it actively. He later explained that when it has happened he will sit for a few minutes and then either extend it with his arm or let it go back on its own. He testified that the pain in both knees on several occasions had woken him up at night. He further testified he experiences knee pain sitting in his desk at work and his knees pop walking up and down stairs. He stated that he can walk about an eighth of a mile. The Veteran was afforded another VA examination in May 2010. The Veteran reported he has constant knee pain at a level of 4-6 out of 10 that flares to 8-9 out of 10 with no particular pattern two the three times a week for a number of hours. The Veteran stated he can walk a half mile before knee pain forces him to stop. He stated that he wears elastic sleeves on his knees about three times a week for six to eight hours while he is at work. He reported that occasionally his knees will swell and feel as if they will lock. At times he said he feels they may give way, but he does not fall. The examiner noted some mild tenderness to palpation over the patellofemoral joint but otherwise no significant tenderness. He found no evidence of instability in either knee. The Veteran said he has never been hospitalized or had surgery on his knees. The examiner found his knee reflexes to be 2+. Strength and muscle tone was found normal in his lower extremities. The Veteran was able to flex both knees from 0 to 130 degrees, although he reported pain at the extremes of his range of motion. The examiner found no evidence of laxity of the cruciate or the collateral ligaments and found the knees to be stable. The patellar compression test was slightly positive, producing some moderate pain but the examiner did not find patellar crepitus. The Veteran was able to do a squat to about 90 degrees flexion of his knees before reporting pain prevented further motion. The examiner found no change in active or passive range of motion during repeat motion testing and no additional losses of range of motion of the knee joints due to pain, weakness, impaired endurance, fatigue, incoordination, or flare-ups. The examiner diagnosed mild to moderate bilateral patellofemoral syndrome. The examiner stated he found no evidence of instability of the knees on examination, noting instability had also not been found at the Veteran's recent VA orthopedic clinic visits. An August 2010 VA orthopedic clinic note relates that the Veteran continued to complain of pain in the front of his knees and some on the sides. The physician found no effusion in either knee, no palpable crepitus with patellofemoral compression. He found the Veteran had mild tenderness to palpation along his iliotibial bands bilaterally and was tender to palpation at the inferior poles of his patella and with patellofemoral compression. He noted the Veteran's knees were stable to anterior/posterior varus/valgus stresses. Looking first at the limitation of motion of the Veteran's knee, the Board notes that his bilateral knee extension has consistently been measured to 0 degrees. For a 20 percent rating under Diagnostic Code 5261, extension must be limited to 15 degrees, therefore the Veteran is not entitled to a higher rating under that code. The Veteran's left knee has shown some limitation of flexion, but not to the 30 degrees required for a 20 percent disability rating under Diagnostic Code 5260. In August 2006 flexion of left knee was measured to 130 degrees. In August 2007 flexion of his left knee was measured to 78 degrees. In January 2009 his knee flexion was measured to 110 degrees bilaterally, in September 2009 to 140 degrees bilaterally, and in March and May 2010 to 130 degrees bilaterally. Thus, the Veteran has consistently had flexion measured at greater than 45 degrees, the minimum limitation required for compensable, 10 percent, evaluation under Diagnostic Code 5260. However, the RO nonetheless awarded the Veteran a 10 percent rating based on his limited and painful motion. The Board has also considered DeLuca, 8 Vet. App. 202, and the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45. Although the Veteran has consistently reported pain at the end of his range of flexion on examinations, the VA examiners in August 2006, January 2009, and May 2010 all noted that with repetitive motion there was no increase in fatigue, decreased range of motion, weakness, or incoordination. The January 2009 examiner did note increased pain in the Veteran's left knee with repetitive motion. At the January 2009 examination the Veteran also estimated that a flare-up would decrease his range of motion by 30 percent. It is important for the Veteran to understand that even if accurate, such a reduction would not reduce his flexion to 45 degrees or less. The Veteran's medical records do not otherwise indicate the Veteran experiences a significant loss of range of motion with flare-ups. Although the Veteran testified at his February 2010 Board hearing that once or twice his knee had locked up, preventing him from immediately extending it, the examiner at his subsequent March 2010 examination noted only that the Veteran reported that occasionally his knees feel as if they might lock. No other treatment records reflect any complaints of either knee locking, raising a question as to the accuracy of the Veteran's testimony. The Board finds that the Veteran's currently assigned 10 percent rating takes into consideration the Veteran's complaints of pain and limitation of motion with flare-ups, and his condition does not more accurately approximate the criteria for a 20 percent rating. As the evidence does not suggest a significant change in the Veteran's symptoms over the course of his appeal, the Board finds a staged rating is not applicable. The Veteran has contended, including at his February 2010 Board hearing, that he experiences knee instability, making his disability potentially ratable under Diagnostic Code 5257 for recurrent subluxation or lateral instability. The Board recognizes the Veteran's complaints that his knees have given out. However, the Veteran's left knee has been consistently found not to have instability at multiple VA examinations and medical appointments. Specifically, the August 2007 VA examiner stated that on limited examination the Veteran's knees appeared stable. In January 2009, although the Veteran told the examiner his left knee had given way three to four times, on examination the examiner found the Veteran's knees were stable and the varus, valgus, anterior, and posterior drawer and McMurray were all normal. In July 2009 the Veteran told the doctor at the VA orthopedic clinic that he did not experience instability in his knees, but sometimes his knees would give way. The doctor found the Veteran's knees to be stable to anterior, posterior, and varus and valgus stressing. At a follow-up appointment at the VA orthopedic clinic in March 2010 the doctor again noted no knee instability and a negative McMurray. In May 2010 the Veteran again told a VA examiner that sometimes his knees feel like they will give way, but the examiner found no evidence of instability on examination. At an August 2010 VA orthopedic clinic visit, a doctor also noted that the Veteran's knees were stable to anterior/posterior, varus/valgus stresses. Overall, the description offered by the Veteran that his knees sometimes either give way or feel as if they might, is too vague of a description from which to discern whether there is true lateral instability. In this instance, the Board is more persuaded by the clinical testing conducted by medical professionals specifically to determine the presence and extent of lateral instability. Based on the results of that testing, which is uniformly negative, the Board finds that there is no lateral instability in the Veteran's left knee. The evidence also does not support that the Veteran experiences recurrent subluxation. Therefore, the Board finds the Veteran is not entitled to a separate rating under Diagnostic Code 5257. At his February 2010 Board hearing the Veteran testified that on one or two occasions his knee had locked up for 20 to 30 minutes during which time he was unable to move it actively, although the May 2010 examiner stated that the Veteran reported only that his knees occasionally feel as if they will lock. While the Board has considered this complaint in evaluating the totality of the Veteran's knee condition, it is not sufficient to warrant a rating under Diagnostic Code 5258, as the medical evidence does not show the Veteran's semilunar cartilage is dislocated. The Board observes it is also neither contended nor shown that the Veteran's service-connected left knee disability involves ankylosis (Diagnostic Code 5256), removal of semilunar cartilage (Diagnostic Code 5259), nonunion of tibia and fibula (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263). Hence, ratings under those diagnostic codes may not be assigned. As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine does not apply, and the claim for an increased disability rating for left knee patellofemoral pain syndrome must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's service connected left knee patellofemoral pain syndrome that would render the schedular criteria inadequate. The Veteran's symptoms, including pain and reduced range of motion are contemplated in the rating assigned. As such, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. Moreover, even if it were argued that the schedular rating criteria were inadequate, the Board finds no reason to refer the case to the Compensation and Pension Service to consider whether an extra-schedular rating is warranted. In this case, there is no evidence of any hospitalization associated with the Veteran's left knee patellofemoral pain syndrome. In addition, the Board finds the record does not reflect that the Veteran's left knee patellofemoral pain syndrome markedly interferes with his ability to work. See 38 C.F.R. § 4.1 (indicating that generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability). In fact, the May 2010 examiner noted the Veteran had held a sedentary office job for the past three years and had not been incapacitated at work by any of his symptoms. The manifestations of the Veteran's disability are considered by the schedular rating. Based on the foregoing, the Board finds the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). Bilateral Carpal Tunnel Syndrome Diagnostic Code 8515 relates to impairments of the median nerve and provides that a 10 percent disability evaluation is assigned for mild, incomplete paralysis of the median nerve of the minor or major hand. Important for this case, a 20 percent disability evaluation is warranted for moderate, incomplete paralysis of the minor hand, and a 30 percent disability evaluation is contemplated for moderate, incomplete paralysis of the major hand. A 40 percent disability evaluation is warranted for severe, incomplete paralysis of the minor hand, and a 50 percent disability evaluation is contemplated for severe, incomplete paralysis of the major hand. A 60 percent disability evaluation is contemplated for complete paralysis of the minor hand, and a 70 percent disability evaluation is contemplated for complete paralysis of the major hand. 38 C.F.R. § 4.124a, DC 8515. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. 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 Veteran in this case is right-handed. The Veteran was afforded a VA examination in August 2006. He reported constant wrist pain at 6-7 out of 10, reduced to 2 out of 10 with the use of aspirin. He reported flare-ups to pain of 8-9 out of 10, especially with activities like using a weed eater or mowing the law. He reported decreased grip strength although denied having dropped anything or a reduction in range of motion. The examiner noted he had decreased sensation in the palmar surface of his right thumb, index finger, and the radial half of the second digit. He also had reduced grip strength. On his left, he was hypoesthetic on the thumb, index finger, and middle finger on the palmar surface. He had no increase in fatigue, decreased range of motion, or increased pain, weakness, or incoordination with repetitive motion. In a statement dated May 2007 the Veteran stated that his wrist had gotten worse, making it difficult to open containers and resulting in increased pain with typing, writing, and holding items. At an August 2007 VA examination the Veteran reported he often has a sensation of swelling and tingling in his hands and he has constant, chronic swelling. He reported his hands had gotten weaker although he had not dropped anything. He stated that the pain is not constant but his numbness and tingling worsen with activity. He stated that typing for more than 20 to 30 minutes causes pain in his hands. He did not report wrist joint pain or flare-ups. Examination of his bilateral hands and wrists demonstrated flexion to 70 degrees, extension to 40 degrees, radial deviation to 20 degrees, and ulnar deviation to 45 degrees on repetitive attempts with no pain on motion. He had normal range of motion of his fingers. His strength was 3/5 and sensation was normal. The examiner noted mild overall enlargement of the Veteran's digits. In an August 2007 statement the Veteran's wife said that the vibration from using a weed eater makes the Veteran's hands useless for several hours and causes pain for several days. During the Veteran's January 2009 VA examination, the Veteran reported having pain at various points throughout an eight-hour work day, totaling about 3 hours per day and exacerbated by typing. He stated that he took Motrin to relieve the pain and wore braces a couple of days per week. He told the examiner that during a flare-up he would have increased pain, decreased range of motion by 40 percent, weakness, fatigue, and incoordination. He reported when it is bad he cannot pick up a coffee cup. He reported numbness in the fourth and fifth digits and on the ulnar side of the hand, with tingling in the other digits, approximately once a week. Bilateral wrist flexion was measured to 55 degrees, extension to 55 degrees, radial deviation at 15 degrees, and ulnar deviation at 40 degrees, all with pain at the end. No change was noted with repetitive motion. Tinel sign at the wrist and Phalen's test gave him pain and numbness and tingling into the fourth and fifth digits. Strength and sensation were normal and there was no swelling or atrophy. The examiner stated that the Veteran's carpal tunnel symptoms have an overlap with ulnar cubital tunnel syndrome at the elbow. The Veteran testified during the February 2010 hearing that, in addition to numbness in the hands, his thumbs have locked and experienced spasms lasting 5 to 15 minutes. He also said his pinky finger often goes numb while he types. He reported that the numbness occurs twice per week, usually when typing though sometimes when driving. He reported wearing braces on both wrists and taking the anti-inflammatory medication Diclofenac. The Veteran underwent a VA examination in May 2010. The Veteran reported he began having numbness in his fingers in 2006 that initially came and went, but has become more frequent recently. He said he wakes nearly every morning with numbness in his thumb, index, and middle fingers of both hands that will clear after five to 10 minutes. He reported infrequent burning pain in the palms of his hands. The Veteran said he wears braces on his wrists about twice a week for a few hours at work, usually near the end of the day after he has been typing. He said his grip feels weak at times and he may drop things such as soap or cup. Infrequently he said his thumbs lock in the flexed position. He has no swelling in his hands, fingers, or wrists. The examiner found no muscle atrophy, including in the intrinsic muscles of the Veteran's hands. On strength testing, the examiner stated that the Veteran failed to give full effort, but momentarily demonstrated normal strength before giving way due to lack of cooperation. The examiner diagnosed probable mild to moderate carpal tunnel syndrome bilaterally. The examiner stated that the Veteran has some sensory impairment not only in the distribution of the median nerves bilaterally but also some sensory loss in the distribution of the sensory branches of the radial nerves as well as some sensory branches of the ulnar nerves. However, the examiner stated there is no evidence to suggest the presence of radial or ulnar neuropathy, raising a question as to the authenticity of the Veteran's reporting of his sensory loss. The examiner further noted there is no motor loss. Considering all of the Veteran's symptoms as he reported them and as noted at his multiple VA examinations, the Board finds that a 30 percent rating is warranted for the Veteran's right wrist carpal tunnel syndrome as of February 12, 2010, the date on which his testimony at his Board hearing reflects that his disability picture more nearly approximates moderate paralysis of the median nerve. However, a rating above 10 percent is not warranted prior to that date as the evidence reflects the Veteran's symptoms during that period are adequately contemplated by the currently assigned 10 percent disability rating. The evidence reflects that prior to February 2010, the Veteran experienced only intermittent numbness and tingling due to his carpal tunnel syndrome. In August 2007 at a VA examination he stated that the numbness and tingling is brought on by activity. At a VA examination in January 2009 he reported numbness occurred only once a week in the fourth and fifth digits with tingling in the other digits. Further, his sensation was found to be normal at VA examinations in August 2007 and January 2009, although some decreased sensation was noted in his August 2006 examination in the palmar surface of his right thumb, index finger, and the radial half of the second digit. On examinations, the Veteran did not demonstrate any decrease in range of motion. He reported flare-ups of pain only with activity such as extended typing. At his January 2009 examination the Veteran reported that when his condition was bad he would be unable to pick up a coffee cup, both otherwise although he reported reduced grip strength he said he had never dropped anything. The January 2009 examiner found the Veteran's strength to be normal on examination. Based on the foregoing, the Board finds the Veteran's symptoms prior to February 12, 2010, which are not constant and do not include a reduction in range of motion, are contemplated by the 10 percent rating assigned. At his February 12, 2010 Board hearing the Veteran reported increased carpal tunnel symptoms, specifically locking of his thumbs in the flexed position and spasming of his thumbs. At his May 2010 VA examination he clarified that the locking has been occurring infrequently over the past several months. Also at his Board hearing the Veteran reported experiencing numbness twice a week, usually while typing, although sometimes while driving. In May 2010 at a VA examination he reported that every morning he had numbness in his thumb, index, and middle fingers that resolved in five to 10 minutes. The Veteran also reported at his May 2010 VA examination that he sometimes drops things such as soap or a cup due to weakness in his grip. On examination the examiner opined that the Veteran did not give full effort on muscle testing, demonstrating normal strength only momentarily. Giving the Veteran the benefit of the doubt, the Board finds a 30 percent rating is warranted for the Veteran's right wrist carpal tunnel syndrome from February 12, 2010 as the evidence suggests his disability picture, including his reports of thumb locking and spasming and intermittent numbness and weakened grip, more nearly approximates moderate paralysis of the median nerve at that point. A higher evaluation, requiring severe, incomplete paralysis, is not appropriate in this case as the Veteran's most serious symptoms are not constant, but rather intermittent, or in the case of his thumb locking and spasming, infrequent. As the evidence indicates no difference in symptomatology between the Veteran's right and left carpal tunnel symptoms, the Board finds that for the same reasons discussed above, the Veteran is also entitled to an increased rating for his left wrist carpal tunnel syndrome as of February 12, 2010, but not prior. Moderate, incomplete paralysis of the minor hand is rated at 20 percent rather than the 30 percent rating for the major hand. As the Veteran's left hand is his minor hand, the Board finds he is entitled to a 20 percent rating as of February 12, 2010. As discussed above, he is not entitled to a rating in excess of the currently assigned 10 percent prior to that date. In reaching this determination, 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. That doctrine, however, is not applicable with regard to a rating in excess of 10 percent prior to February 12, 2010 because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55; 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. The Board has also considered whether referral for consideration of an extraschedular rating is warranted. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's service connected carpal tunnel syndrome that would render the schedular criteria inadequate. The Veteran's symptoms, including numbness, pain, and weakness, are contemplated in the rating assigned. As such, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. Moreover, the Board notes there is no evidence of any hospitalization associated with the Veteran's carpal tunnel syndrome. In addition, the Board finds the record does not reflect that the Veteran's carpal tunnel syndrome markedly interferes with his ability to work. In fact, the May 2010 examiner noted the Veteran had held a sedentary office job for the past three years and had not been incapacitated at work by any of his symptoms. The manifestations of the Veteran's disability are considered by the schedular rating. Based on the foregoing, the Board finds the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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, 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. 38 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in July 2006. In the letter, the RO informed the Veteran of what evidence was required to substantiate his claims and of the Veteran's and VA's respective duties for obtaining evidence. In the letter the RO also provided notice with regard to how VA assigns disability ratings and effective dates in the event that service connection is established. The claim for a higher initial rating arises from the Veteran's disagreement with the initial rating assigned after the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records identified by the Veteran. The Veteran has also submitted personal lay statements and a statement by his spouse. Neither the Veteran 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. Also, in Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the VLJ who conducts a hearing fulfill two duties to comply with the regulation. They 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. In this case, during the February 2010 Board videoconference hearing, the VLJ fully explained the issue on appeal. The Veteran was assisted at the hearing by an accredited representative from the Disabled American Veterans, and the VLJ and the representative asked questions regarding the Veteran's symptoms, where the Veteran obtained medical treatment, and if all current records had been obtained. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. 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), and that any error in notice provided during the Veteran's hearing constitutes harmless error. VA also must provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Veteran was afforded VA medical examinations in August 2006, August 2007, January 2009, and May 2010. The examiners, medical professionals, obtained an accurate history and listened to the Veteran's assertions. The examiners provided the Board with sufficient information to rate the Veteran's disabilities. Therefore, the Board finds that the examinations are adequate and contain sufficient information to decide the issues on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist 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, 16 Vet. App. 183. ORDER An initial rating in excess of 10 percent for the Veteran's left knee patellofemoral pain syndrome is denied. An initial rating in excess of 10 percent prior to February 12, 2010 for the Veteran's bilateral carpal tunnel syndrome is denied. A rating of 30 percent, but no higher, is granted for the Veteran's right wrist carpal tunnel syndrome from February 12, 2010, subject to the laws and regulations controlling the disbursement of monetary benefits. A rating of 20 percent, but no higher, is granted for the Veteran's left wrist carpal tunnel syndrome from February 12, 2010, subject to the laws and regulations controlling the disbursement of monetary benefits. REMAND The Board notes that the Veteran was granted service-connection for right knee patellofemoral pain syndrome based on a VA examination performed shortly following his release from service that found limited and painful motion with patellofemoral pain syndrome diagnosed. As discussed above with respect to the left knee, the medical evidence also consistently failed to show any instability in the Veteran's right knee, despite the Veteran's generalized complaints that his knees would sometimes give out or feel like they were going to. However, VA treatment records suggest that the Veteran's right knee condition may have worsened after a January 2012 fall. In January 2012 the Veteran was seen at the VA emergency department complaining of right knee pain after slipping on the stairs and feeling his right knee pop. He was unable to extend his right knee fully. X-rays showed mild tricompartmental osteoarthritis in the right knee. In February 2012 the Veteran reported to his VA doctor that his right knee intermittently would collapse with ambulation. In March 2012 he reported ongoing swelling and medial sided knee pain. On examination his knee was stable with anterior/posterior varus/valgus stresses, but he had a positive McMurray's at the medial aspect of his knee. A March 2012 MRI of the Veteran's right knee showed a complex through and through radial and oblique tear of the posterior and posteromedial medial meniscus, significant femoral condyle cartilage loss in the medical compartment, a possible tear of the oblique fibers of the medial collateral ligament, and large joint effusion. In May a VA doctor diagnosed a right posterior medical meniscus tear after reviewing the MRI. The Veteran complained of pain along the medial joint line in his right knee as well as knee effusions that wax and wane. The examiner found the Veteran's knee was tender to palpation along the medial joint like with 2+ effusion. The knee was stable with anterior, posterior, and varus/valgus stress, but had a positive McMurray's. The doctor noted the Veteran's joint spaces are relatively well-preserved and he only became symptomatic in his right knee after his twisting injury, which may have been the source of his meniscal injury. An arthroscopic partial medial meniscectomy was planned. Thus, it appears the Veteran has suffered an additional right knee injury since his discharge from service and his right knee condition has worsened since his last VA examination. At this point, the evidence is insufficient for the Board to rate the Veteran's service-connected right knee disability in light of the subsequent intercurrent injury. The Board may compensate the Veteran only for his service-connected disability. The Board, however, is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Accordingly, this appeal requires determination, to the extent possible, as to what are the manifestations of the Veteran's service-connected right knee disability as opposed to manifestations of any nonservice-connected post-service injury. Further, the current severity of the Veteran's right knee patellofemoral pain syndrome should be evaluated. Accordingly, the case is REMANDED for the following action: 1. The RO should obtain all of the Veteran's VA medical records from April 2012 to present and any private treatment records related to his right knee identified by the Veteran. 2. The Veteran should be scheduled for a VA medical examination to determine the current severity of his right knee patellofemoral pain syndrome. The claims file must be made available to and reviewed by the examiner. After a review of the Veteran's claims file, the examiner should identify and distinguish symptoms and impairment attributable to the Veteran's service-connected right knee disability from those attributable to any subsequent, unrelated right knee injury (unless it is indicated - at least as likely as not - that the new right knee injury was caused by the service connected right knee disability). If the physician finds that it is not possible to separate the effects of the Veteran's service-connected right knee disability from the effects of any post-service (intercurrent) right knee injury, all such signs and symptoms (and associated impairment of function) must (as required by governing law/case law ) be attributed to the service-connected left right disorder. The physician must explain in detail the rationale for all conclusions reached. 3. The case should be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter 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). ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs