Citation Nr: 1324249 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 09-21 867 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wilmington, Delaware THE ISSUES 1. Entitlement to a compensable initial rating for residuals of right wrist strain/sprain. 2. Entitlement to a compensable initial rating for residuals of left wrist strain/sprain. REPRESENTATION Appellant represented by: Delaware Commission of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from October 1987 to October 2007. These matters come to the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office in Newark, New Jersey. During the pendency of this appeal, the Veteran's claim was transferred to the Regional Office in Wilmington, Delaware (RO). In April 2013, the Veteran provided testimony at a Board hearing before the undersigned Veterans Law Judge. A copy of the resulting transcript has been associated with the Veteran's Virtual VA claims file. Preliminarily, subsequent to the most recent adjudication of his above-captioned claims, the Veteran submitted pertinent evidence with a contemporaneous waiver of RO review. As such, the Board will consider such evidence herein. 38 C.F.R. § 20.1304 (2012). The appeal is REMANDED to the RO via the Appeals Management Center in Washington, DC. VA will notify the Veteran if further action is required. REMAND In the May 2008 rating decision, service connection was granted for right and left wrist sprain/strain. In the body of the decision, the RO noted that the Veteran's service treatment record documented treatment for a disability that was diagnosed as tenosynovitis of the hand and wrist. The RO assigned separate noncompensable ratings to the Veteran's right and left wrist sprain/strain pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5024, which specifically concerns tenosynovitis. Diagnostic Code 5024 instructs VA to rate the disability at issue based on limitation of motion under the appropriate diagnostic code, which, in the Veteran's case, is 38 C.F.R. § 4.71a, Diagnostic Code 5215. Based on the above, the Board finds that the scope of the May 2008 grant of service connection for right and left wrist sprain/strain was limited to a musculoskeletal disability of the right and left wrist/hand. Significantly, during the pendency of the appeal with respect to the above-captioned claims, the Veteran submitted evidence demonstrating the presence of left and right wrist/hand vascular and/or neurological symptoms, including a possible diagnosis of Raynaud's disease among others. Raynaud's disease is a disability of the arteries and veins rated under 38 C.F.R. § 4.104, Diagnostic Code 7117. The Veteran has not submitted a claim of entitlement to service connection for Raynaud's disease, or any other vascular or neurological disability associated with his hands/wrists. Nevertheless, it is unclear whether there are vascular and/or neurological components, including Raynaud's disease, of the Veteran's service-connected residuals of right and/or left wrist sprain/strain currently at issue on appeal. Similarly, the Board finds that the record is unclear as to whether the Veteran's reported symptoms of fingertip numbness on VA general medical examination in December 2007 is an aspect of his service-connected right and left wrist sprain/strain, or whether fingertip numbness (among other neurological and vascular symptoms) is an aspect of a separate and distinct disability for which entitlement to service connection has yet to be developed and adjudicated. In this regard, the Board notes that during the VA general medical examination in December 2007, the examiner indicated that the Veteran's reported symptoms, that he experienced numbness in his fingertips for the previous 10 years, would be more specifically addressed in a contemporaneous neurological VA examination. A review of the December 2007 VA neurological examination did not reveal a discussion of the Veteran's reported fingertip numbness. This examination was limited to an assessment of a sleep disorder and dizziness secondary to motion sickness. In view of the foregoing, the Board finds that a remand is required for a VA examination to determine the full nature and extent of the service-connected disabilities at issue. See Littke v. Derwinski, 1 Vet. App. 90, 93 (1990) (holding that a remand may be required if the evidence of record contains insufficient information for evaluation purposes). Generally, all issues "inextricably intertwined" with the issue certified for appeal, are to be identified and developed prior to appellate review. Harris v. Derwinski, 1 Vet. App. 180 (1991). The issues of entitlement to service connection for a vascular and/or neurological disability of the bilateral hand/wrist is "intertwined" with the issue of entitlement to compensable initial ratings for residuals of right and left wrist sprain/strain because a decision on the former claim may have an impact on the latter claims. Consequently, the Board finds that the Veteran's claims of entitlement to compensable initial ratings for his service-connected right and left wrist sprain/strain are remanded to the RO for contemporaneous adjudication. Accordingly, the case is REMANDED for the following action: 1. The RO should provide the Veteran and his representative with VCAA notice as to the issues of entitlement to service connection for a vascular and/or neurological disability of the bilateral wrist/hands as secondary to service-connected residuals of right and left wrist sprain/strain. 2. The Veteran should be provided a VA examination to determine the complete nature, extent, severity, and manifestations of his service-connected residuals of right and left wrist sprain/strain, to include any associated neurological and/or vascular manifestations. The examiner is specifically requested to opine as to whether it is at least as likely as not that any right and/or left wrist/hand neurological or vascular disability identified (to include Raynaud's disease) is a manifestation of, proximately due to, or chronically aggravated by, the service-connected residuals of right and left wrist strain/sprain. The claims file must be made available to, and be reviewed by, the examiner in conjunction with the examination. All orthopedic, muscular, vascular, and neurologic impairment found to be present and attributable to the service-connected residuals of right and left wrist sprain/strain disabilities must be noted. All necessary tests must be conducted, including range of motion testing of the wrists, and all clinical findings must be reported in detail. Range of motion testing results should be expressed in degrees with use of a goniometer, and standard ranges should be provided for comparison purposes. If painful motion is observed, the examiner must state the point in degrees at which motion is limited by pain. The same range of motion studies must then be repeated after at least 5 repetitions. The examiner must also state whether there is any functional loss due to pain, weakened movement, excess fatigability, or incoordination causing additional disability after repetitions of the range of motion tests. With respect to any subjective complaints of pain, the examiner must comment on whether pain is visibly manifested on movement of either wrist, the presence and degree of, or absence of, muscle atrophy attributable to the service-connected wrist disabilities, the presence or absence of changes in condition of the skin indicative of disuse due to the service-connected wrist disabilities, and the presence or absence of any other objective manifestation that would demonstrate disuse or functional impairment due to pain attributable to the service-connected wrist disabilities. Thorough rationales for the opinion(s) expressed should also be provided. If any requested opinion cannot be provided, the examiner must state this and specifically explain why an opinion could not be provided. 3. The RO must notify the Veteran that it is his responsibility to report for the scheduled VA examination, and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. Copies of all documentation notifying the Veteran of the scheduled VA examination must be placed in the Veteran's claims file. 4. Once the above action has been completed, the RO must adjudicate the inextricably intertwined issues of entitlement to service connection for neurological disability, as secondary to service-connected residuals of left and right wrist strain/sprain, and entitlement to service connection for vascular disability, to include Raynaud's disease, as secondary to service-connected residuals of left and right wrist strain/sprain. Notice of the determinations and the Veteran's appellate rights should be provided to the Veteran and his representative. Only if a timely appeal is completed as to either of such determinations, should the issues be forwarded to the Board for appellate consideration. 5. Following completion of the above requested action, re-adjudicate the Veteran's claims of entitlement to compensable initial ratings for service-connected right and left wrist sprain/strain, taking into consideration any newly acquired evidence. If any benefit sought remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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). This claim 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). _________________________________________________ U. R. POWELL 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).