Citation Nr: 1324576 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 06-08 226 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for carpal tunnel syndrome (CTS) of the left wrist. 2. Entitlement to an increased rating for a right wrist strain, currently evaluated as 10 percent disabling. 3. Entitlement to an initial rating in excess of 10 percent for carpal tunnel syndrome of the right wrist. 4. Entitlement to an initial compensable rating for left foot arthritis. 5. Entitlement to a compensable rating for ganglion cyst of the right wrist, status post aspiration. 6. Entitlement to a compensable rating for ganglion cyst of the left wrist, status post aspiration. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Giannecchini, Counsel INTRODUCTION The Veteran had active military service from February 1975 to October 1998. These matters come to the Board of Veterans' Appeals (Board) on appeal following February 2005, February 2006, and January 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In August 2004 and February 2011, the Veteran testified before RO personnel. Transcripts of both hearings are associated with the claims folders. Also, while the Veteran had originally requested a Board hearing, in August 2010, the Veteran requested an RO hearing in lieu of a Board hearing. The Veteran was also denied service connection for arthritis of the hands in a November 2002 rating decision. The Veteran perfected an appeal to the denial of his claims. In a June 2007 rating decision, the RO granted service connection and assigned noncompensable ratings for degenerative joint disease of the five fingers of the right hand as well as degenerative joint disease of the five fingers of the left hand. The RO's award is considered a full grant of the benefits sought on appeal for the claims for service connection for arthritis of the hands. As such, the issue is no longer in appellate status. Likewise, by a January 2010 rating decision, the RO denied the Veteran's claim for service connection for a left hip disability. The Veteran perfected an appeal. In a March 2011 rating decision, the RO granted service connection and assigned a noncompensable rating for degenerative sclerosis of the left acetabulum. The RO's award is considered a full grant of that benefit sought on appeal. As such, the issue is also no longer in appellate status. (The issues of entitlement to service connection for carpal tunnel syndrome of the left wrist, an initial compensable rating for left foot arthritis, and for entitlement to a TDIU are addressed in the remand that follows the decision below.) FINDINGS OF FACT 1. From September 26, 2005, to July 6, 2009, the Veteran's carpal tunnel syndrome of the right wrist more nearly approximated severe incomplete paralysis of the median nerve. 2. From July 6, 2009, the Veteran's carpal tunnel syndrome of the right wrist more nearly has approximated moderate incomplete paralysis of the median nerve. 3. Ankylosis of the right wrist has not been shown. 4. At no time during the claim period does the evidence demonstrate ganglion cysts of either the right wrist or the left wrist; nor has residual disability associated with such cysts been identified. CONCLUSIONS OF LAW 1. From September 26, 2005 to July 6, 2009, the criteria for a rating of 50 percent for carpal tunnel syndrome of the right wrist have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8515 (2012). 2. From July 6, 2009, the criteria for a rating of 30 percent for carpal tunnel syndrome of the right wrist have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8515 (2012). 3. The criteria for a disability rating greater than 10 percent for right wrist strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5215 (2012). 4. The criteria for a compensable disability rating for ganglion cyst of the right wrist, status post aspiration, have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.71a, Diagnostic Codes 5015, 5024 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008); 38 C.F.R. § 4.118, Diagnostic Code 7819 (2012). 5. The criteria for a compensable disability rating for ganglion cyst of the left wrist, status post aspiration, have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.71a, Diagnostic Codes 5015, 5024 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008); 38 C.F.R. § 4.118, Diagnostic Code 7819 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2013). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the claimant to provide any evidence in his possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The Board finds that all notification action needed to make a decision on the claims for higher ratings for right wrist strain; carpal tunnel syndrome of the right wrist; and ganglion cysts of the wrists, status post aspiration, have been met. Through a September 2004 notice letter, the Veteran was notified of the information and evidence needed to substantiate his claims for higher ratings for right wrist strain as well as ganglion cysts of the wrists, status post aspiration. The Board also finds that the September 2004 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be obtained by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letter, the Veteran was notified that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Thereafter, in March 2006, the RO provided the Veteran with the general criteria for assigning disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Although the complete notice was not provided until after the RO initially adjudicated the Veteran's above-noted three claims, the claims were properly re-adjudicated in subsequent supplemental statements of the case (SSOCs). See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). As such, a remand of the claims for further notification is not necessary. With regard to the issue of an initial rating in excess of 10 percent for carpal tunnel syndrome of the right wrist, the claim is a "downstream" issue in that it arose from an initial grant of service connection. Prior to the February 2006 rating decision, a December 2005 notice letter advised the Veteran of the evidence necessary to substantiate his claim for service connection for this disability and of his and VA's respective obligations with regard to obtaining evidence. Quartuccio, supra. As noted above, in March 2006, the RO provided the Veteran with the general criteria for assigning disability ratings and effective dates. Importantly, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim for service connection has been more than substantiated. Once a claimant disagrees with an initial determination, other provisions apply to the remainder of the adjudication process, particularly those pertaining to the issuance of rating decisions and statements of the case (SOCs). See 38 U.S.C.A. §§ 5104(a), 7105(d) (West 2002); 38 C.F.R. §§ 3.103(b)(1), 19.29 (2012); see also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). There is also no indication that any additional action is needed to comply with the duty to assist in connection with the claims the Board has decided below. The Veteran's service treatment records (STRs) are associated with the claims folders as are his VA and private treatment records. Significantly, the Veteran has not otherwise alleged that there are any outstanding medical records probative of his claims being decided that need to be obtained. The Board also notes that the Veteran has been provided a number of VA medical examinations. These examinations provide sufficient evidence by which to evaluate the Veteran's claims for right wrist strain; carpal tunnel syndrome of the right wrist; as well as ganglion cysts of the wrists, in the context of the rating criteria and other medical evidence of record. Therefore, there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims decided herein. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. Where a claimant appeals the denial of a claim for an increased rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of the claimant's disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (where a claimant appealed the initial rating assigned for a disability, "staged" ratings could be assigned for separate periods of time based on facts found). The Board has reviewed all evidence in the claims folders and in the Veteran's electronic case file (Virtual VA), with an emphasis on the evidence relevant to his claims decided below. Although the Board has an obligation to provide reasons and bases supporting its decision, the Board is not required to discuss, in detail, every piece of evidence of record. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). As such, the Board will summarize the relevant evidence and the analysis will focus on what the evidence shows, or fails to show, as to the claims. Finally, it remains the responsibility of the Board, in this instance, to interpret 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 present. See 38 C.F.R. § 4.2 (2012). CTS of the Right Wrist Ratings for impairment of the upper extremities depend on which extremity is the major (dominant) extremity, meaning the one predominantly used by the individual. 38 C.F.R. § 4.69 (2012). Medical treatment records reflect that the Veteran is right-hand dominant, and the Board's analysis will reflect this finding. The Veteran's carpal tunnel syndrome of the right wrist is evaluated as paralysis of the median nerve under Diagnostic Code 8515. 38 C.F.R. § 4.124a, Diagnostic Code 8515. For median nerve impairment of the major (dominant) extremity, mild incomplete paralysis warrants a 10 percent evaluation, moderate incomplete paralysis warrants a 30 percent evaluation, severe incomplete paralysis warrants a 50 percent evaluation, and complete paralysis of the median nerve of the major extremity warrants a 70 percent evaluation. Id. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120 (2012). The terms "mild," "moderate," and "severe" are not defined in the rating schedule. It should also be noted that use of such terminology by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. The record as a whole is evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). The pertinent evidence reflects an October 2004 MRI (magnetic resonance imaging) scan of the right wrist. In particular, findings were suspicious for a partial tear and possibly partial detachment of the triangular fibrocartilage at its attachment on the ulnar styloid. It was also noted that there was no definite evidence to indicate carpal tunnel syndrome. A March 2005 EMG/NCS impression revealed abnormality due to prolonged distal latencies in the right and left median compound motor action potential as well as sensory nerve action potential. Needle EMG studies demonstrated some acute denervation changes affecting the abductor pollicis brevis muscles in both hands. The muscles were innervated by their respective median nerves below the wrist. The clinician noted that overall, the studies suggested a bilateral moderately severe carpal tunnel syndrome. A report of January 2006 VA examination notes that the Veteran wore a brace on his right wrist daily and at night. The Veteran complained of daily pain and weakness associated with his right wrist, as well as numbness of his fingers. In a report of January 2007 VA examination, the examiner noted the Veteran's complaints of paresthesia in the right hand along with fatigue and diminished grip strength. Diminished sensory testing associated with the right median (nerve) distribution was noted. The examiner commented that there was some thenar wasting in the right hand. The diagnosis was carpal tunnel syndrome. A report of July 6, 2009 VA examination noted the Veteran's complaint of occasional tingling in the right hand twice a month and that he controlled symptoms with the use of a brace on the wrist at night. Clinical findings revealed normal vibratory sensation on the right upper extremity and normal reflexes. There was also a normal motor examination of the right arm without atrophy. Otherwise, there was a positive Tinel's sign but negative Phalen's sign. The examiner described neuritis without muscle wasting of the right wrist. The diagnosis was carpal tunnel syndrome of the right wrist. A July 2009 private treatment record revealed a normal light touch and pain sensory evaluation of C7, C8, and T1 to include peripheral distribution. The assessment was wrist pain a result of overuse syndrome. In a report of October 2009 VA examination, the examiner noted the Veteran's complaint of mild constant aching pain in the right wrist which could flare to severe sharp pain due to prolonged (two to five minutes) of the right hand. The pain was alleviated by rest and warming the hand/wrist. On clinical evaluation grip strength was 4/5 with sensory and motor testing of the right upper extremity within normal limits. The examiner's diagnosis included "right wrist strain and carpal tunnel syndrome, moderate." In an April 2012 VA DBQ (disability benefits questionnaire), sensory and motor testing of the right upper extremity was within normal limits. The examiner's diagnosis included carpal tunnel syndrome of the right wrist. The disability was noted to be painful and affect the Veteran's ability to lift and carry objects. The Veteran's hearing testimony is consistent with the history reported to medical examiners. In particular, the Veteran has described a dull aching pain in the right wrist that increases in severity with use. Taking into account the March 2005 diagnostic study reflecting "moderately severe" carpal tunnel syndrome, as well as the reported objective clinical findings of record and the Veteran's complaints of pain and functional loss with prolonged use of the right wrist, the Board concludes that since the initial grant of service connection, September 26, 2005 to July 6, 2009, the disability picture associated with the Veteran's carpal tunnel syndrome of the right wrist more nearly approximates severe incomplete paralysis of the median nerve. As such, a rating of 50 percent is found warranted effective from September 26, 2005, to July 6, 2009. Otherwise, during this period the medical evidence does not demonstrate complete paralysis of the median nerve. The Veteran retained functional use of his right hand and fingers. While the January 2007 VA examiner noted some thenar wasting in the right hand, the July 2009 VA examiner found no evidence of muscle wasting. Notwithstanding the later negative finding, the thenar wasting found in January 2007 was not identified as considerable (one of the criteria for complete paralysis of the median nerve) and the reference to "some" wasting by the examiner along with the Veteran's other symptoms at that time does not otherwise approximate complete paralysis. The Board also finds that since the report of July 6, 2009 VA examination, the disability picture associated with the Veteran's carpal tunnel syndrome of the right wrist more nearly approximates moderate incomplete paralysis of the median nerve. As such, a rating of 30 percent is found warranted effective from July 6, 2009. See e.g., O'Connell v. Nicholson, 21 Vet. App. 89 (2007) (regulation requiring 60-day notice of rating reduction was not applicable to staged rating). During this period the medical evidence does not demonstrate severe incomplete paralysis or complete paralysis of the median nerve. Here, the objective clinical findings do not reflect abnormal sensory or motor testing of the right upper extremity. Furthermore, the October 2009 VA examiner described the Veteran's right wrist disability, to include carpal tunnel syndrome, as "moderate" in degree. Notwithstanding this evidence, the Board has taken into consideration additional functional loss due to carpal tunnel syndrome of the right wrist associated with prolonged use. In light of the functional loss based on pain and nerve impairment, a 30 percent rating based on moderate incomplete paralysis is warranted. In reaching the above determinations , the Board has considered 38 C.F.R. §§ 4.40 and 4.45 (2012). See DeLuca v. Brown, 8 Vet. App. 202 (1995) (38 C.F.R. §§ 4.40 and 4.45 are applicable to disabilities involving the musculoskeletal system, including the muscles, nerves, and joints. See also Id. at 204 (discussing § 4.40, which provides that functional loss may be due to "defective innervation" and pain). Furthermore, the Board has taken into consideration the rule against pyramiding in assigning the higher disability ratings for the Veteran's disability. See 38 C.F.R. § 4.14 (2012). (As discussed below, the Veteran is in receipt of a 10 percent disability rating for right wrist strain.) Therefore, for all the foregoing reasons, the Board finds that since the initial grant of service connection, September 26, 2005, to July 6, 2009, a rating of 50 percent, and no higher, for service-connected carpal tunnel syndrome of the right wrist is warranted. Additionally, since July 6, 2009, a rating of 30 percent, and no higher, for service-connected carpal tunnel syndrome of the right wrist is warranted. Right Wrist Strain The Veteran's right wrist strain has been rated as 10 percent disabling by the RO under the provisions of Diagnostic Code 5215. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The only available schedular evaluation for limitation of motion of the wrist is 10 percent for either the minor or major extremity, and that requires either dorsiflexion of less than 15 degrees or palmar flexion limited in line with the forearm. In this case, the Board notes that the Veteran is presently receiving the maximum schedular rating available under Diagnostic Code 5215. A higher evaluation can only be awarded if ankylosis of the right wrist is demonstrated. The Board's review of the medical evidence of record does not reflect the Veteran's right wrist is ankylosed. Otherwise, when evaluating musculoskeletal disability, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases, as previously discussed, in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca v. Brown, 8 Vet. App. 202 (1995). See also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). However, in light of the holding in Johnston v. Brown, 10 Vet. App. 80 (1997), the Veteran is not entitled to a higher rating based on functional loss because 10 percent is the maximum rating available under Diagnostic Code 5215. Otherwise, as noted above, the Veteran is being additionally compensated for neurological symptomatology associated with his service-connected carpal tunnel syndrome of the right wrist. See Brady v. Brown, 4 Vet. App. 203, 206 (1993) (the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology); 38 C.F.R. § 4.14. The Board has also considered whether separate ratings are warranted for each limitation of movement of the Veteran's right wrist. See Plate One § 4.71 (portrays measurements of ankylosis and joint motion in addition to four different potential limitations of motion of the wrist-dorsiflexion (extension), palmar flexion, ulnar deviation, and radial deviation). As noted above, Diagnostic Code 5215 provides two separate ratings of 10 percent for limited dorsiflexion of the wrist and for palmar flexion of the wrist limited in line with the forearm. A review of the medical evidence does demonstrate a significant loss in ulnar deviation of the right wrist on VA examinations in July 2007. At that time, ulnar deviation was reported as 10 degrees (normal is 45 degrees). Otherwise, range of motion associated with ulnar deviation was full on VA examinations in September 2004, January 2006, July 2009 and April 2012. The VA regulations applicable to the wrist, Diagnostic Code 5215 as well as Diagnostic Code 5214 (for ankylosis), allow for an evaluation for ulnar or radial deviation only when that motion of the wrist is ankylosed. As the evidence does not reflect ankylosis of the right wrist in ulnar or radial deviation, a separate evaluation for limited ulnar or radial deviation of the right wrist is not warranted. Otherwise, the medical evidence does not reflect dorsiflexion of less than 15 degrees or palmar flexion limited in line with the forearm. As such, the Board does not find separate 10 percent disability ratings are warranted based on limited dorsiflexion or palmar flexion of the right wrist. Therefore, for all the foregoing reasons, the Board finds that a rating higher than 10 percent for service-connected right wrist strain is not warranted. Ganglion Cysts of the Wrists, Status Post Aspiration When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical location and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). All three factors must be addressed and not merely one factor. Lendenmann v. Principi, 3 Vet. App. 345, 351 (1992). Ganglion cysts are disabilities unlisted in the rating schedule. The RO has evaluated the ganglion cysts of the wrists, status post aspiration, under Diagnostic Code 5015 for "bones, new growths, benign" and Diagnostic Code 7804 for "scars". See 38 C.F.R. § 4.71a, Diagnostic Code 5015; 38 C.F.R. § 4.118, Diagnostic Code 7804. The disabilities have been assigned noncompensable disability ratings. Under Diagnostic Code 5015, a disability is evaluated based on limitation of motion of the affected parts, as degenerative arthritis. As noted above, limitation of motion of the wrist is rated under Diagnostic Code 5215. 38 C.F.R. § 4.71a, Diagnostic Code 5215. Presently, the Veteran is receiving a 10 percent rating for right wrist strain under Diagnostic Code 5215. He is also receiving a 10 percent rating for degenerative joint disease of the left wrist, which takes into consideration Diagnostic Code 5215. Thus, consideration of a compensable evaluation of the service-connected ganglion cysts, status post aspiration, based on limitation of motion of the wrists is prohibited based on the rule against pyramiding. 38 C.F.R. § 4.14. Also, during the pendency of this appeal, the schedular criteria by which skin disabilities are rated were revised, effective October 23, 2008. See 73 Fed. Reg. 54,708 (September 23, 2008). These revisions are applicable only to claims filed on or after October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The Veteran's claims for compensable ratings for ganglion cysts status post aspiration were already pending as of October 23, 2008. Under Diagnostic Code 7804, in effect on and after August 30, 2002 (and prior to October 23, 2008), scars which are superficial and painful on examination are rated as 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Note 1 to Diagnostic Code 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. Note 2 to Diagnostic Code 7804 provides that a scar on a tip of the finger or toe still would warrant the 10 percent evaluation. The Board has also considered the Veteran's ganglion cysts under Diagnostic Code 5024 for tenosynovitis. See 38 C.F.R. § 4.71a, Diagnostic Code 5024. Tenosynovitis is also rated based on limitation of motion of the affected parts, as degenerative arthritis. Furthermore, the Board has considered the Veteran's ganglion cysts under Diagnostic Code 7819 for benign skin neoplasms. See 38 C.F.R. § 4.118, Diagnostic Code 7819. Under this diagnostic code, the neoplasm is rated as scars or is based on the limitation of motion of the part affected. In the instant case, the Veteran had ganglion cysts of the right wrist and the left wrist aspirated during active service. Since that time, the Veteran has not had a recurrence of the ganglion cysts. In a report of May 2005 VA examination, an examiner noted that the Veteran had no symptoms associated with the aspiration of the cysts in service. Furthermore, there were no scars associated with the aspiration of the cysts and there was no pain or adherence at the aspiration sites. The examiner also commented that a previously discussed March 2005 MRI revealed tenosynovitis of the right wrist without occult fracture and a subcondylar cyst with arthritic changes. In a subsequent report of July 2009 VA examination, an examiner commented that the Veteran had had the ganglion cysts removed and there had been no recurrence. Here, the medical evidence does not reflect any residual disability, to include residual scarring, associated with the aspirated ganglion cysts of the wrists. Therefore, in light of the above, and the lack of clinical evidence of right and/or left wrist ganglion cysts or residual disability associated with such cysts, the Board finds that compensable ratings for right wrist and/or left wrist ganglion cysts, status post aspiration, is not warranted. Consideration under 38 C.F.R. § 3.321(b)(1) Consideration has been given by the Board as to whether the schedular evaluations are inadequate, requiring that the RO refer any of the claims to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation. Such a referral is warranted where a service-connected disability presents an exceptional or unusual disability picture that renders impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a claimant's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this regard, the analysis must include a discussion of whether the rating criteria adequately address all of the claimant's symptomatology. Also, extra-schedular ratings under 38 C.F.R. § 3.321 are awarded on a disability-by-disability basis for each individual disability being considered and not on the combined effect of all of a claimant's service-connected disabilities. See Johnson v. Shinseki, 26 Vet. App. 237 (2013). The Veteran's primary symptoms associated with his overall right wrist disability (strain and carpal tunnel syndrome) includes pain, loss of motion, as well as loss of grip strength. The rating criteria under 38 C.F.R. § 4.124a, Diagnostic Code 8515 (for incomplete and complete paralysis of the median nerve) as well as 38 C.F.R. § 4.71a, Diagnostic Code 5215 (for limitation of motion of the wrist) contemplate these symptoms. Otherwise, no residual disability has been identified by the medical evidence relating to ganglion cysts. Thus, the first step of the Thun analysis for all three service-connected disabilities, whether the rating criteria adequately address all of the claimant's symptomatology for each disability, has been met. As such, the Board's extra-schedular analysis for each disability ends, and consideration of the second step-whether the claimant's exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization-is not warranted. Therefore, without sufficient evidence reflecting that the Veteran's individual disability picture associated with his disabilities is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture related to his carpal tunnel syndrome of the right wrist; right wrist strain; as well as ganglion cysts of the wrists, requires the assignment of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1); Thun, supra. Therefore, for all the foregoing reasons, the Board finds since the initial grant of service connection, September 26, 2005, to July 6, 2009, a rating of 50 percent, and no higher, for service-connected carpal tunnel syndrome of the right wrist is warranted. Additionally, since July 6, 2009, a rating of 30 percent, and no higher, for carpal tunnel syndrome of the right wrist is warranted. Also, the criteria for a rating higher than 10 percent for right wrist strain and the criteria for compensable ratings for ganglion cysts of the wrists have not been shown. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims for any higher rating than that assigned, that doctrine is not helpful to the Veteran. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102. ORDER From September 26, 2005 to July 6, 2009, a rating of 50 percent for carpal tunnel syndrome of the right wrist is granted, subject to the laws and regulations governing the award of monetary benefits. From July 6, 2009, a rating of 30 percent for carpal tunnel syndrome of the right wrist is granted, subject to the laws and regulations governing the award of monetary benefits. A rating higher than 10 percent for right wrist strain is denied. A compensable rating for ganglion cyst of the right wrist, status post aspiration, is denied. A compensable rating for ganglion cyst of the left wrist, status post aspiration, is denied. REMAND Following its review of the claims folders, the Board finds that additional VA examinations should be undertaken with regard to the Veteran's claim for service connection for carpal tunnel syndrome of the left wrist and his claim for an initial rating in excess of 10 percent for left foot arthritis. In a report of a January 2006 VA examination, an examiner opined that the Veteran's carpal tunnel syndrome of the left wrist was not related to service as the Veteran's STRs did not document treatment for symptoms suggestive of carpal tunnel syndrome. In an October 2010 private medical opinion, the Veteran's treating private physician noted that he had been asked to comment on the likelihood that the Veteran's current musculoskeletal and neurological problems were possibly related to medical problems that he experienced in service. The physician commented: I have reviewed the denial decision as well as [the Veteran's] service medical records, and I have concluded that more likely than not, [the Veteran's] current problems do date back to his service time. My experience has been that seemingly benign musculoskeletal injuries become, with the passage of time, more bothersome, and sometimes more incapacitating. The Board notes that carpal tunnel syndrome, as noted in the decision above, is evaluated based on impairment of the median nerve. The Veteran is service connected for a left wrist ganglion cyst, which was aspirated during active service. He has alleged that his carpal tunnel syndrome of the left wrist is related, or could be related, to his ganglion cyst (also, as noted above, the Veteran is service connected for degenerative joint disease of the left wrist). While not exactly clear, the Board assumes that the private physician's statement contemplates the Veteran's carpal tunnel syndrome of the left wrist. In light of the two medical opinions, and the uncertainty regarding the private medical opinion, the Veteran should undergo a VA examination to allow a clinician opportunity to review all the evidence of record, to include the most recent October 2010 opinion, and provide a fully-informed assessment as to whether the Veteran has carpal tunnel syndrome of the left wrist, and if so, the nature and etiology of the disability. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). With regard to the Veteran's service-connected left foot arthritis, the arthritis, per X-rays, is located in the interphalangeal joints of the left toes. The Veteran has also been treated for nonservice-connected plantar fasciitis of the left foot. In considering the Veteran's left foot arthritis, the RO concluded that the disability did not approximate moderate foot injuries (disability) under Diagnostic Code 5284. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). During his February 2011 hearing, the Veteran testified that he experienced a great deal of discomfort in his left foot. He described it feeling like he was walking on hot coals. Methods he used to ameliorate the pain and burning sensation, orthotics and balms, had not worked well enough to allow him to work full time or otherwise remain active. The Board's review of the claims folders does not reflect medical evidence that adequately addresses the Veteran's left foot complaints or distinguishes the symptomatology associated with the arthritic left toes from the plantar fasciitis. Furthermore, in light of the Veteran's report that his left foot affects his ability to work, the disability could influence any consideration of an extra-schedular rating under 38 C.F.R. § 3.321 or the issue of a TDIU rating. Thus, the Board believes the Veteran's left foot should be examined and the examiner provide a fully-informed assessment as to the nature and etiology of the Veteran's left foot pain and burning sensation. Stefl, supra. As any decision with regard to the claims involving carpal tunnel syndrome of the left wrist and left foot arthritis could have a bearing on the Veteran's claim for a TDIU, the issue of a TDIU is deferred pending completion of the development sought in this remand. Accordingly, the case is REMANDED for the following action: 1. Obtain any available VA treatment records dated since July 2011. (The Veteran appears to receive his treatment through the VA Central Texas Health Care System.) 2. After completion of the above (and allowing a reasonable amount of time to obtain any identified records), schedule the Veteran to undergo appropriate VA examinations pertaining to any carpal tunnel syndrome of the left wrist as well as left foot arthritis. The claims folders and a copy of this remand must be reviewed by the examiner(s) in conjunction with the examinations. Any tests and studies deemed necessary should be conducted and the clinical findings should be reported in detail. Carpal Tunnel Syndrome-- The examiner should elicit a detailed history from the Veteran concerning problems with his left wrist. The examiner's claims folders review should include a review of the Veteran's service treatment records and tabbed documents pertaining to carpal tunnel syndrome, to include a January 2005 private physician's treatment report (see Volume 4 of the claims folders), a report of a January 2006 VA examination in which a VA examiner opined that the Veteran's carpal tunnel syndrome of the left wrist was not related to service (see Volume 4 of the claims folders), and an October 2010 private medical opinion in which the Veteran's treating private physician appears to relate left wrist problems to service (see Volume 5 of the claims folders). Following examination of the Veteran and review of the claims folders, the examiner should offer his/her opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater), that any diagnosed carpal tunnel syndrome of the left wrist had its onset during military service or is otherwise related to military service. The medical basis for any conclusion reached should be thoroughly explained. Left Foot Arthritis-- The examiner should elicit a detailed history from the Veteran concerning problems with his left foot. The examiner's claims folders review should include, in particular, a review of those tabbed documents pertaining to the left foot. The Veteran is service connected for left foot arthritis, in particular, the toes of the left foot (the arthritis was identified on X-ray as affecting the interphalangeal joints of the left foot toes). The Veteran also receives treatment for nonservice-connected plantar fasciitis of the left foot. Following examination of the Veteran and review of the claims folders, the examiner should report his or her findings (to include any loss in range of motion) and also offer answers to the following: a. Does the Veteran have arthritic changes associated with his left foot and/or toes? b. Does the Veteran have plantar fasciitis? c. Are the Veteran's complaints of pain and a burning sensation in his left foot (see February 2011 hearing transcript in Volume 5 of the claims folders) due to any identified left foot arthritis or plantar fasciitis, or otherwise related to some other left foot disorder? d. Does the Veteran suffer from functional or occupational limitations due to any identified arthritis? With respect to impairment due to arthritis, all limitations of motion of the foot and toes caused by arthritis should be set forth in detail, and all functional losses due to pain, weakness, etc., should be equated to additional loss of motion (beyond what is shown clinically). The medical basis for each conclusion reached should be thoroughly explained. 3. Following the development above, undertaken any additional development deemed appropriate or suggested by the evidence obtained. Thereafter, readjudicate the issues remaining on appeal-entitlement to service connection for carpal tunnel syndrome of the left wrist, entitlement to an initial compensable rating for left foot arthritis, and entitlement to a TDIU. (If the examination associated with the Veteran's left foot reveals findings that the Veteran's service-connected arthritis in his left foot/toes does result or interfere with his employment or employability, the agency of original jurisdiction (AOJ) should refer the claim for service connection for left foot arthritis to the appropriate VA official for consideration of an extra-schedular rating under 38 C.F.R. § 3.321(b).) Thereafter, if any of the benefits sought remains denied, the Veteran and his representative should be provided a SSOC and given an appropriate opportunity to respond. The case should then be returned to the Board for further consideration, if otherwise in order. 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 case must be afforded expeditious treatment. The law requires that all claims 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. 2013). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs