Citation Nr: 1326942 Decision Date: 08/22/13 Archive Date: 08/29/13 DOCKET NO. 04-16 137 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah THE ISSUES 1. Entitlement to a compensable initial disability rating for a right hand episodic paraesthesia secondary to overexertion syndrome. 2. Entitlement to a compensable initial disability rating for a left hand episodic paraesthesia secondary to overexertion syndrome. 3. Entitlement to a compensable initial disability rating for a right foot paraesthesia secondary to overexertion syndrome. 4. Entitlement to a compensable initial disability rating for a left foot paraesthesia secondary to overexertion syndrome. REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from July 1985 to July 2008. This appeal comes before the Board of Veterans' Appeals (Board) from an April 2013 Order of the United States Court of Appeals for Veterans Claims (Veterans Court). The appeal originates from an October 2008 rating decision of the RO in Salt Lake City, Utah. In a May 2012 decision, the Board denied compensable initial disability ratings for paresthesias of the bilateral hands and feet. The Veteran appealed that decision to the Veterans Court. The April 2013 Order of the Veterans Court granted a Joint Motion for Partial Remand, vacated the Board's May 2012 decision in part, and remanded these issues back to the Board for development consistent with the Joint Motion. In the May 2012 decision, the Board also denied entitlement to an initial rating in excess of 10 percent for the Veteran's service-connected right hip disorder. The Joint Motion stipulated that the Board's decision with respect to that issue should not be disturbed, effectively affirming the decision. In reviewing this case the Board has not only reviewed the physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. For the entire period of this appeal, the neurological disability of the bilateral hands has been manifested by intermittent tingling, numbness, and pain, but has not been productive of mild incomplete paralysis of the effected nerves. 3. For the entire period of this appeal, the neurological disability of the bilateral feet has been manifested by subjective reports of tingling, numbness, and pain, but has not been productive of moderate incomplete paralysis of the effected nerves. CONCLUSIONS OF LAW 1. The criteria for a compensable initial disability rating for an episodic paraesthesia of the right hand secondary to overexertion syndrome has not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8515 (2012). 2. The criteria for a compensable initial disability rating for an episodic paraesthesia of the left hand secondary to overexertion syndrome has not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8515 (2012). 3. The criteria for a compensable initial disability rating for a paraesthesia of the right foot secondary to overexertion syndrome has not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8522 (2012). 4. The criteria for a compensable initial disability rating for a paraesthesia of the left foot secondary to overexertion syndrome has not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8522 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has claimed entitlement to compensable initial disability ratings for his service-connected bilateral hand and foot paresthesias. Each of these conditions has been rated as noncompensably disabling. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. When the schedule does not provide a zero percent evaluation for in a Diagnostic Code, a zero percent evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term incomplete paralysis indicates a degree of lost of impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at time excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. The Veteran's bilateral hand paresthesias have been rated pursuant to Diagnostic Code 8599-8515 and his bilateral foot paresthesias have been rated pursuant to Diagnostic Code 8599-8522. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.127 (2012). When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be assigned as follows: the first two digits will be selected from that part of the schedule most closely identifying the part, or system of the body involved, in this case, the neurologic system, and the last two digits will be 99 for all unlisted conditions. Then, the disability is rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27 (2012). Diagnostic Code 8515 governs paralysis of the median nerve. A 70 percent rating is available for complete paralysis of the major arm (60 percent minor) with 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; pain with trophic disturbances. For incomplete paralysis that is severe, a 50 percent rating is available for the major arm (40 percent minor); for incomplete paralysis that is moderate, a 30 percent rating is available for the major arm (20 percent minor); and for incomplete paralysis that is mild, a 10 percent rating is available for either arm. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715. Diagnostic Code 8522 governs paralysis of the musculocutaneous nerve (superficial peroneal). A 30 percent rating is available for complete paralysis with eversion of the foot weakened. For incomplete paralysis that is severe, a 20 percent rating is available; for incomplete paralysis that is moderate, a 10 percent rating is available; and for incomplete paralysis that is mild, a 0 percent rating is for assignment. 38 C.F.R. § 4.124a, Diagnostic Codes 8522, 8622, 8722. After a review of the evidence, the Board finds that the weight of the evidence is against entitlement to compensable disability ratings for the Veteran's service-connected bilateral hand and foot paresthesias. The Board finds initially that the Veteran does not actually have incomplete paralysis or any of the other conditions specified in the rating criteria. The criteria for rating the peripheral nerves provide ratings based on the present of neuritis, neuralgia and paralysis. In this case, the April 2010 VA examiner found no neuritis, no neuralgia, and no paralysis, providing highly probative evidence against these claims. The June 2008 VA examiner found no paresis or paralysis of the upper or lower extremities, providing more evidence against these claims. The Board also notes that findings for neurological impairment have been essentially normal throughout the period on appeal. These include sensation, reflexes, peripheral pulses, motor strength, and muscular atrophy. A very comprehensive VA examination was conducted in June 2008. The report shows complaint of pain in the right forearm below the elbow more than the left side in the same area. Whenever the elbow area hurts, which is more on the lateral aspect, the complete forearm and the complete hand feel a little numbness and tingling, but then if goes off, and he rests. The examiner found no typical evidence of any Raynaud's, no locking of the fingers or the thumb, and no forearm muscular weakness or hand weakness. There was no typical evidence of any median or ulnar or radial nerve distribution pathway involvement and clinical symptoms do not match the picture of a cubital tunnel. At the time of the examination, the Veteran denied any finger joint or thumb pains. Even on the hand, there was no particular area of numbness and tingling because, as the Veteran described it, symptoms come and go. The examiner found no residuals on the hands. There was no pain or swelling. The Veteran described that his feet are only symptomatic when he is standing for long periods of time in one place without moving for 15 minutes or more, and then, he gets a little bit of numbness. The examiner found no features of numbness or tingling involving the lateral, medial, or plantar aspect of the foot, and no metatarsalgia. The Veteran denied any pain under the sole of the foot. On examination of both upper extremities, deep tendon reflexes were normal, as were findings for vascularity and muscle tone, and sensory-motor findings. Bilateral median nerves, ulnar, and radial nerves were intact. Tinel's sign was negative, and Phalen's test was negative at the sites of entrapment. The ulnar nerve was normal in palpation and was symmetrical. Hyperflexion of the elbow and hyper-extension did not cause any numbness or tingling, and there was no typical feature of any median, ulnar, or radial nerve distribution sensorimotor alteration. Wrist movements were normal with no pain at the wrists. Bilateral thumbs and fingers were normal. Grasp-release was normal. Fingers could touch the midpalmar crease. The thumb could touch the tips of the fingers. All muscle strengths were intact, including the first dorsal interossei and the hypothenar and the thumb intrinsic muscles. The thumb could touch the 5th digit volar metacarpophalangeal joint creases satisfactorily. Froment's test was negative. There was no swelling of any joints, and no Raynaud's findings. The left hand 5th digit had normal function. The examiner found no disability, and no evidence of any flexion- extension problems. Interphalangeal joints were normal. Metacarpophalangeal joints were normal. Bilateral forearm musculature was normal, providing more evidence against these claims. On examination of the lower extremities, straight leg raising tests were negative. Lasegue's test was negative. Reflexes were normal. There was no swelling of any joint. Extensor hallucis longus had normal function, and 5 out of 5 strength. There were no paresthesias detected in the feet. There was no metatarsalgia or tarsal tunnel syndrome. The strength of the intrinsic muscles was normal, and he responded to touch, pressure, pinch, and touch sensation normally in the hind foot, mid foot, and distal foot. Posture and gait were normal, providing more evidence against these claims. Findings on non-VA evaluations appear consistent with the June 2008 examination. Physical therapy reports from Evans Army Hospital in July, August, October, and November 2007 reveal that wrist/hand strength was 5 out of 5, providing significant evidence against these claims. More importantly, neurological evaluations from Evans Army Hospital in February 2008, April 2008, and October 2008 revealed no neurological symptoms or neurological systems normal, providing highly probative evidence against these claims. A February 2009 report from Evans Army Hospital shows that testing for numbness and tingling in various nerve distributions produced negative results. The neurological examination was normal. No sensory abnormalities were noted. Reflexes were normal. Motor examination showed no dysfunction. A range of motion examination was performed and overall findings were normal. The fingers and hands showed no abnormalities, providing more evidence against these claims. A June 2009 report from Evans Army Hospital shows that motor strength was tested, and there was no weakness in the wrists. A September 2009 report from Evans Army Hospital reveals no neurological symptoms. Pedal pulses were 1+ bilaterally. Neurological examination revealed 100 percent proprioception bilaterally. Monofilament testing was intact bilaterally. Vibratory sense was intact in both feet. Balance was normal, and gait and stance were normal. A report from July 2009 also reveals that posture, gait, and stance were normal. In August 2009, it was noted that there was no ankle swelling. A September 2009 report from Evans Army Hospital reveals the Veteran's functional status as "no physical disability." The Veteran was noted to enjoy fishing and hiking. The Veteran's gait was steady and unassisted. The lower extremities were without edema. A November 2009 report from Evans Army Hospital reveals that no neurological symptoms were found on examination. The pain scale was 0 (pain free). Peripheral vascular examination was normal, with no intermittent leg claudication; no cold hands or feet and no sudden onset of cold extremities. Additional VA examinations were also conducted. A March 2010 VA hypertension examination reveals no swelling of the feet; peripheral pulses were equal and 4+/5 bilaterally, in the posterior tibial, dorsalis pedis, popliteal, femoral and radialis pulses. There was no peripheral edema. The report of VA diabetes mellitus examination in April 2010 reveals normal upper and lower extremity muscle strength, fine motor control, and muscle tone. Upper and lower extremity pulses were normal. Also normal were tests for pinprick, temperature sense, position sense, vibration sense, and two point discrimination in the upper and lower extremities. The report of VA examination in June 2010 reveals no muscle wasting, muscle atrophy, loss of motor control, or lesions of the upper or lower extremities. Pulses were normal. Testing for pinprick, temperature sense, position sense, vibration sense, and two point discrimination in the upper and lower extremities were also normal, providing more evidence against these claims. Regarding the effect of the disability on employment, a March 2010 hypertension examination reveals that the Veteran was working as a computer operator and he reportedly missed only five days of work for the prior 12 months, and this was due to common colds. The Veteran was able to function in his usual occupation. Activities of daily living were found not to be impaired. The Veteran reported doing light shoveling and bicycling. His gait was normal. He was using no assistive devices. He had no difficulty arising from a chair or changing positions on the examination table. In sum, the Board is presented with a clinical record showing essentially no measurable disability of the peripheral nerves on what can only be considered a rather consistent and prodigious scale by both VA a non-VA medical sources, over several years, and these clinical findings incorporate and are consistent with the Veteran's descriptions of his symptoms to the examiners. Notwithstanding the above, the parties to the Joint Motion stipulated that the Board did not adequately address certain evidence of record in its prior decision. In this regard, the parties identified a private physical therapy report dated March 2, 2009, at which time the Veteran complained of bilateral hand and wrist pain. The physical therapist found that there were mild limitations on wrenching, holding and fastening nuts and bolts, brushing teeth, holding a cup of coffee, and computer tasks. The parties cited this report as evidence against the Board's finding as to functional impact. In light of the evidence as a whole, the Board assigns little probative weight to the March 2, 2009 physical therapy report regarding establishing the Veteran's overall level of functional impairment for the primary reason that this "initial evaluation" was followed less than 20 days later (March 20, 2009) by a "discharge note" on which he was found to have no limitation of wrenching, holding and fastening nuts and bolts, brushing teeth, and holding a cup of coffee, and only had a mild limitation regarding computer tasks. Whatever deficits the Veteran may have had at the onset of treatment were apparently quickly remedied by his course of physical therapy. Notwithstanding the fact that even the initial findings are in coflict with specific neurological testing conducted on numerous occasions throughout the period on appeal, the Board finds that a period of less than 20 days does not represent the Veteran's overall impairment during the period on appeal, and does not represent a sustained increase in the level of disability upon which to base a staged rating. The parties to the Joint Motion also identified statements made by the Veteran in correspondence pertaining to his appeal, notably the VA Form 9. There, he reported "constant pain and impact my life." He provided the example: "it is hard to repair my vehicles when I can't hold a wrench, home repairs are not so easy when I can not grasp a saw or use hand tools. Not to mention that I can not stand for a long length of time because my feet go numb." He further stated that sitting in an airplane or traveling in an automobile was difficult because his hands and feet went numb. In this regard, it is important for the Veteran to understand that the Board did take into consideration the Veteran's statements in its prior determination. The Board finds that the Veteran's description of symptoms and effects made to VA in pursuit of this claim conflicts with what he has repeatedly described to medical examiners, as well as with the test results and clinical findings made by those examiners. It is impossible to reconcile the Veteran's description of his inability to hold a wrench or a saw with the consistent findings of normal strength, normal muscle tone, normal grip strength and finger range of motion, and normal neurological findings, including specific testing for numbness and tingling, and with the Veteran's description of his symptoms to the June 2008 examiner that, in certain circumstances, he will experience a little numbness and tingling, but that he was not even experiencing those minimal symptoms when examined. Further, not only are the assertions made in VA Form 9 not supported by the clinical evidence, they are in many cases specifically refuted by the clinical evidence, and by the Veteran's own description of symptoms to medical examiners. In this case, in many instances, in the Veteran's own description of this issue provides highly probative evidence against his claims. Based on the above, the Board finds that the Veteran's assertions as to his symptoms, as reported on the VA Form 9, and at other points, are outweighed by the other evidence of record that clear providers highly probative evidence against the Veteran's claims. The parties also identified the VA examination on June 11, 2010 wherein the examiner reported that the disability limits prolonged sitting or standing and limits repetitive use of the hands. The Board finds that, in light of the completely normal neurological findings reported by the June 2010 examiner, such a finding is not supportable. Moreover, the examiner contradicted himself in the same report: Just above the cited finding, he answered "no" to the question regarding whether there are any functional limitations on standing and walking. The Board is more persuaded by the examiner's essentially normal clinical findings than by his self-contradictory summation of functional impairment, particularly in light of the evidence as a whole, which include many statements from the Veteran himself to examiners which provide highly probative evidence against this own claims. Regarding the Veteran's account of pain, which has ranged from none at all to severe, the Board notes that while pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. The clinical findings above demonstrate that there is no significant functional loss of the hands or feet associated with the service-connected disabilities. As noted above, significant evidence of high probative value clear indicates no compensable disability associated with the Veteran's service connected disabilities at this time (some of this evidence coming from the Veteran's own prior statements). The Board has addressed the Veteran's contentions in the VA Form 9, and has found them to be inaccurate based on a detailed review of the evidence as a whole including, but not limited to, the Veteran's own statements over time and the detailed statement he has made to examiners and other regarding the nature and extent of the problem (or lack thereof) associated with these service connected conditions. In this case, the evidence deemed to be most persuasive by the Board indicates that "symptoms", to the extent they are present at all, are occasional, at very best, and are productive of no significant functional impairment. Mild incomplete paralysis of the median nerves is not shown or approximated. Moderate incomplete paralysis of the musculocutaneous nerves is not shown, nor is it more nearly approximated than mild incomplete paralysis. For these reasons, the Board finds that the weight of the evidence is against compensable initial disability ratings for the service-connected paresthesias of the bilateral hands and feet. To the extent any higher level of compensation is sought, the preponderance of the evidence is against these claims, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular scheduler standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, 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. Therefore, 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, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board has found that much of the Veteran's account as to the description of his symptoms cited in the 1-9 is not correct, and that the clinical evidence is more reliable as to his symptomatology and level of impairment. The Board finds that the schedular rating criteria contemplate the Veteran's service-connected symptoms, which include intermittent pain, numbness, and tingling of the hand and feet. The criteria specifically provide for ratings based on the presence of neurological symptoms and resulting functional impairment. Such factors are explicitly part of the schedular rating criteria, and higher ratings are available where appropriate symptomatology is demonstrated. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Repeated direct and indirect references in this record to the fact that these conditions do not impact the Veteran only supports this finding. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Veterans Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Because this appeal arises from the Veteran's disagreement with the initial evaluations following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Veterans Court have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, and the Veteran's written assertions. Regarding private treatment records, the Veteran identified records from Warrior Medical Clinic, Evans Army Hospital, and Falcon Physical Therapy. Those records were eventually obtained, either directly from the provider or submitted by the Veteran. In addition, the Veteran was afforded several VA examinations to evaluate his service-connected neurological symptoms, the most recent in June 2010. This examination was adequate because it was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The examination report includes findings pertinent to the rating criteria. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). ORDER A compensable initial disability rating for a neurological disability of the right hand is denied. A compensable initial disability rating for a neurological disability of the left hand is denied. A compensable initial disability rating for a neurological disability of the right foot is denied. A compensable initial disability rating for a neurological disability of the left foot is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs