Citation Nr: 1323677 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 09-22 434 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to a rating in excess of 20 percent for carpal tunnel syndrome affecting the left upper extremity (hereinafter "left CTS disability"). 2. Entitlement to a rating in excess of 30 percent for carpal tunnel syndrome affecting the right upper extremity (hereinafter "right CTS disability"). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The Veteran served on active duty from August 1991 to May 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) New Orleans, Louisiana. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the Veteran if further action is required. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that she is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Veteran is seeking a higher disability rating for her service-connected left and right CTS disabilities, which are rated 20 and 30 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code (DC 8515), respectively. Diagnostic Code 8515, which provides the rating criteria for paralysis of the median nerve, states that a 10 percent rating is assigned for mild incomplete paralysis of the median nerve for both the major and minor extremity. Moderate incomplete paralysis of the median nerve warrants the assignment of a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Severe incomplete paralysis warrants the assignment of a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. Complete paralysis of the median nerve warrants the assignment of a 60 percent rating for the minor extremity and a 70 percent rating for the major extremity. Complete paralysis of the median nerve contemplates such symptoms as the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. The Veteran has asserted that her left and right CTS disabilities are under-evaluated as they do not adequately consider the functional impairment caused by the disabilities. See July 2013 Brief. In this regard, the Veteran has asserted that she is unable to grasp and hold objects for any length of time and that she is unable to perform simple daily functions. As an initial matter, the Board finds there may be outstanding medical evidence pertinent to the claims on appeal. At the January 2009 neurologic examination, the examiner noted that the Veteran was scheduled for additional diagnostic tests and possible surgery by civilian physicians within the next few weeks. Other than the July 2007 and January 2009 VA examination reports, the evidentiary record only contains an April 2007 treatment record from Dr. K.R., which shows the Veteran had a recurrence of CTS symptoms following surgery in June 2006 and that she was scheduled for follow-up. There are no additional treatment records from Dr. K.R. or any other private health care provider associated with the record, including records dated after January 2009. Therefore, on remand, the agency of original jurisdiction (AOJ) should obtain any outstanding treatment records from Dr. K.R. and any other healthcare provider identified by the Veteran. The Board also notes that the Veteran was afforded a VA examination in July 2007, which, in pertinent part, evaluated the range of motion in the bilateral wrists and fingers, the sensory impairment of the left and right upper extremities, and the scars associated with the left and right CTS disabilities. In January 2009, the Veteran was afforded a VA neurologic and scar examination which, in pertinent part, evaluated the sensory impairment of the left and right upper extremities and the scars associated with the left and right CTS disabilities. The physician who conducted the January 2009 VA neurologic examination noted that the Veteran has bilateral hand grip weakness and that she continues to work as a typist, with pain and painful paresthesias becoming more disabling. Likewise, the physician who conducted the January 2009 VA scars examination noted that there are two linear scars on the left and right upper extremity which were not tender to palpation on objective examination. Notably, however, the VA neurologic physician did not report the range of motion of the Veteran's bilateral wrists and fingers. Based on the foregoing, the Board finds that the VA examinations conducted in January 2009 were inadequate, as they did not include all information and evidence needed to adequately evaluate the service-connected left and right CTS disabilities. Additionally, as the evidence indicates that the Veteran may possibly have undergone surgery for such disabilities and her most recent VA examination is over four years old, the Board finds that a remand is necessary in order to afford the Veteran a VA examination in order to assess the current nature and severity of her service-connected left and right CTS disabilities. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter requesting that she identify any healthcare provider who has treated her left and right carpal tunnel syndrome disabilities, including Dr. K.R. After securing any necessary authorization from her, obtain all identified treatment records, to include those from Dr. K.R., dated from June 2006 to the present. All reasonable attempts should be made to obtain any identified records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e) . 2. After all outstanding records have been associated with the claims file, schedule the Veteran for an appropriate VA examination to evaluate the current nature and severity of her service-connected left and right CTS disabilities. Any indicated evaluations, studies, and tests should be conducted. The claims folder must be made available to the examiner for review prior to the examination, and the examination report should reflect that review of the record was accomplished. The examiner should identify the nature and severity of all manifestations of the left and right CTS disabilities, including, but not limited to, range of motion of the wrists and fingers, motor and muscle function, and sensory impairment of the extremities. The examiner must comment on the impact the Veteran's service-connected left and right CTS disabilities have on her employability, to include whether such renders her unemployable. All opinions expressed must be accompanied by supporting rationale. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). _________________________________________________ A.JAEGER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).