Citation Nr: 1334166 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 06-03 762 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for impingement of a nerve, to include pain in the right arm, shoulder, elbow, and chest, also claimed as thoracic outlet syndrome and bone abnormality of the shoulder blade. 2. Entitlement to service connection for chronic fatigue syndrome. 3. Entitlement to service connection for a cervical spine disability. 4. Entitlement to an initial rating for varicose veins of the right lower extremity, post-phlebitic syndrome, in excess of 20 percent prior to April 25, 2012 and in excess of 40 percent from April 25, 2012. 5. Entitlement to an initial rating for status post ulnar nerve entrapment of the right wrist in excess of 10 percent disabling from August 30, 2005, and in excess of 30 percent disabling from April 25, 2012. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from February 1978 to February 1983 and from January 1987 to January 1992. These matters come before the Board of Veterans' Appeals (Board) from a September 2006 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in New York, New York. These matters were most recently before the Board in May 2013 when they were remanded for further development. The issues of entitlement to service connection for impingement of a nerve (to include pain in the right arm, shoulder, elbow, and chest) also claimed as thoracic outlet syndrome and bone abnormality of the shoulder blade, and entitlement to service connection for a cervical spine disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The most probative evidence of record reflects that the Veteran does not have a current diagnosis, or symptoms of chronic fatigue syndrome. 2. Prior to April 25, 2012, the Veteran's varicose veins of the right lower extremity, post-phlebitic syndrome disability was manifested by complaints of swelling; objectively there was no finding of had persistent edema and stasis pigmentation or eczema. 3. From April 25, 2012, the Veteran's varicose veins of the right lower extremity, post-phlebitic syndrome disability has been manifested by complaints of swelling; objectively, there is no finding of massive board-like edema with constant pain at rest or persistent ulceration. 4. Prior to October 8, 2007, the Veteran's status post ulnar nerve entrapment was manifested symptoms consistent with no more than mild incomplete paralysis. 5. From October 8, 2007 to November 7, 2011, the Veteran's status post ulnar nerve entrapment was manifested by complaints of paresthesias and dysesthesias of the right hand from the wrist to the fingertips, and decreased grasp strength, consistent with no more than moderate incomplete paralysis. 6. From November 7, 2011 to April 25, 2012 the Veteran's status post ulnar nerve entrapment was manifested by symptoms and EMG/NCS results reflective of no more than mild right ulnar neuropathy at the level of the elbow. 7. From April 25, 2012 the Veteran's status post ulnar nerve entrapment was manifested by complaints numbness, tingling, and weakness in the right hand and numbness and tingling in the right medial upper arm, consistent with no more than moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). 2. The criteria for a rating for varicose veins of the right lower extremity, post-phlebitic syndrome, in excess of 20 percent prior to April 25, 2012 and in excess of 40 percent from April 25, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7121 (2013). 3. The criteria for a rating for status post ulnar nerve entrapment of the right wrist in excess of 10 percent disabling prior to October 8, 2007 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8516 (2013). 4. The criteria for a rating for status post ulnar nerve entrapment of the right wrist of 30 percent and no higher, from October 8, 2007 to November 7, 2011 have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8516 (2013). 5. The criteria for a rating for status post ulnar nerve entrapment of the right wrist in excess of 10 percent from November 7, 2011 to April 25, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8516 (2013). 6. The criteria for a rating for status post ulnar nerve entrapment of the right wrist in excess of 30 percent disabling from April 25, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8516 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in February, March, and May 2006. The appeal with regard to the varicose veins of the right lower extremity, post-phlebitic syndrome, and status post ulnar nerve entrapment of the right wrist stem from the Veteran's disagreement with the initial evaluations following the grants of service connection. Once service connection is granted the claim is substantiated, and additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of the claim, which is not abrogated by the granting of service connection. The claim file includes service treatment records (STRs), post service medical records, and the statements of the Veteran in support of the claims. The file also includes a February 2013 VA Formal Finding on the Unavailability of records from Charleston Naval Hospital, and a May 2012 National Personnel Records Center negative response to a request for records for the Charleston Naval Hospital under the Veteran's maiden name. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that adequate VA examinations/opinions are of record for the issues decided herein; they are predicated on consideration of the Veteran's disabilities, her symptoms, diagnostic testing, and her medical history. Adequate rationale was provided for the opinions offered. In addition, the reports contain information necessary to evaluate the disabilities under the applicable diagnostic code rating criteria. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher 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 favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating post-phlebitic Syndrome (DC 7121) A 100 percent rating is provided for massive board-like edema with constant pain at rest. A 60 percent rating is provided for persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 40 percent rating is provided for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 20 percent rating is provided for persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. A 10 percent rating is provided for intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. Asymptomatic palpable or visible varicose veins warrants a noncompensble rating. The above evaluations are for involvement of a single extremity. If more than one extremity is involved, each extremity is evaluated. Rating the Ulnar Nerve (DC 8516) DC 8516 provides for the rating for paralysis of the ulnar nerve, and therefore neuritis and neuralgia of that nerve. Complete paralysis of the ulnar nerve of the major upper extremity, which is rated 60 percent disabling, contemplates a "griffin claw" deformity due to flexor contraction of the right and little fingers, very marked atrophy in the dorsal interspaces and the thenar and hypothenar eminences, loss of extension of the right and little fingers, an inability to spread (or reverse) the fingers, an inability to adduct the thumb, and weakness of the flexion of the wrist. Disability ratings of 10 percent, 30 percent and 40 percent are assignable for incomplete paralysis of the ulnar nerve of the major upper extremity, which is mild, moderate, or severe in degree, respectively. DC 8616 refers to neuritis of the sciatic nerve, and DC 8716 refers to neuralgia of the sciatic nerve. Those disabilities are rated using the same criteria. Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Entitlement to service connection for chronic fatigue syndrome The Veteran contends that she has chronic fatigue syndrome due to active service. Initially, the Board notes that the Veteran's DD 214 for the period January 1987 to January 1992, her second and final period of service, reflects that she did not have foreign service. It reflects five months of sea service; however, it does not reflect decorations, medals, badges, citations, and/or campaign ribbons which reflect or suggest that she had service in the Southwest Asia theater of operation. An essential element for service connection is a current disability. The Board finds, for the reasons noted below, that the evidence is against a finding that the Veteran has chronic fatigue syndrome in accordance with 38 C.F.R. § 4.88a; thus, service connection is not warranted. For VA purposes, a diagnosis of chronic fatigue syndrome requires: (1) New onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) The exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) Six or more of the following: i. Acute onset of the condition ii. low grade fever iii. nonexudative pharyngitis iv. palpable or tender cervical or axillary lymph nodes v. generalized muscle aches or weakness vi. fatigue lasting 24 hours or longer after exercise vii. headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state) viii. migratory joint pains ix. neuropsychologic symptoms x. sleep disturbances A June 2006 VA examination report reflects that the Veteran did not have chronic fatigue syndrome. The examiner opined, in pertinent part, as follows: The joint conditions that the veteran claims include right shoulder elbow wrist dysfunction, costochondritis, thoracic outlet syndrome of the right. However, documentation provided by personal physicians attributes these conditions to an acute torn rotator cuff for which she had surgery March 13 2006. She was discharged from the service in 1992 so there is no diagnosis while active duty that pertains to her current medical conditions of the skeletal system on the right upper extremity. . . . In terms of the claim for the chronic fatigue syndrome, the veteran does not meet the VA criteria for this syndrome. In an addendum, the examiner stated, as follows: It is important to note during the history taking the discrepancy between veteran's claims of today and essentially negative review of systems for skeletal and spinal disorder in September 2004, the veteran became angry tearful, paced, trembled, and ascribed her lack of complaints of September 2004 due to state of mind after a psychological evaluation. However this is not noted in the history of that date as anything remarkable in her affect or behavior. A July 2010 VA examination report is also of record. The July 2010 VA examination report reflects that the examiner considered the primary signs and symptoms of chronic fatigue and compared them to the Veteran's STRs and post service records. The examiner found that it is "not at least as likely as not that the Veteran fulfills the criteria for a diagnosis of chronic fatigue syndrome." In part, the examiner noted the following: on March 27 1991 the Veteran reported to sick call complaining of fatigue and indicated that she could sleep all of the time. This was written off as a viral syndrome. Several entries in the service medical records also indicate fatigue. As late as 2005 the Veteran was employed as an LPN working in excess of 45 hours a week. There is mention of both fatigue and stress due to these circumstances. Throughout both periods of military service there are repetitive visits to sick call for repetitive sore throats and upper respiratory infections. There is evidence of record of poor sleep and depression in the second period of service. The examiner considered the Veteran's complaints of fatigue and other symptoms in service and post service, and still opined that the Veteran does not have chronic fatigue syndrome. The examiner noted that the evidence did not reflect migrating joint pain, or extreme exhaustion lasting more than 24 hours after mental or physical activity. The examiner also found that headaches in service were associated with sore throats and viral illnesses, and migraine headaches were noted in medical records; however, it could not be determined whether the Veteran had some new or unique headache representative of a chronic fatigue syndrome. An April 2012 VA examination report is of record. The report reflects that the Veteran does not have and has never been diagnosed with chronic fatigue syndrome. The report reflects that the Veteran reported that she had not been diagnosed with chronic fatigue syndrome, but that she has daily fatigue, her sleep is interrupted 2-3 times nightly with pain and the need to urinate, she has "brain fog" for awhile, frequent dry sore throat, sometimes has lymph node swelling under the right mandibular jaw, bilateral calf pain, and frequent joint pain in the hands, feet, and wrists. Upon examination in 2012, the Veteran had nonexudative pharyngitis, palpable or tender cervical or axillary lymph nodes, and sleep disturbance. It was noted that her symptoms wax and wane. It was noted that her symptoms did not restrict routine daily activities as compared to the "pre-illness" level. It was noted that the Veteran did not have chronic fatigue syndrome that impacted her ability to work. The Board notes that the Veteran is competent to report some of her symptoms (e.g. fatigue, headaches, joint pain); thus, for purposes of completeness, the Board will discuss several of the clinical records which relate to the Veteran's reported symptoms. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to the complexities of numerous symptoms which may be attributed to chronic fatigue syndrome, or to individual disabilities. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In the present case, the Veteran has reported that she is a licensed practical nurse. Thus, she more experience, training, and/or education than the average lay person in medical conditions and etiologies. However, the Board finds that the VA examiner opinions are more probative than the Veteran's opinion. The opinions are provided by three individuals, to include a nurse practitioner, and a physician's assistant, who have more education and training than the Veteran. The Board also notes that the Veteran is not an objective professional in this case. See Cartright v. Derwinski, 2 Vet. App.24, 25 (1991) (finding that, while the Board may not ignore a Veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits, personal interest may affect the credibility of the evidence); see also Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). Importantly, the Board finds that the Veteran's opinion ignores key factors. First, she contends that she has chronic fatigue syndrome as evidenced by fatigue in service; however, she fails to note that she was diagnosed, at times, in service with a viral syndrome which was responsible for her fatigue, and leg pain which kept her from sleeping well at night. Second, her opinion does not take into consideration that working between 40 to 100 hours a week, working the night shift, and sleeping sometimes for only two to three hours at a time may cause fatigue. Third, she has previously contended that her migraines are due to her menstrual cycle and blood pressure during those times, and that her migraines go away as her menstrual cycle ends. Fourth, her various body pains have been related to identified disabilities (e.g. varicose veins and her inability to sleep well at night (leg pain), rotator cuff tear and impingement (shoulder pain), ulnar nerve entrapment (arm and hand symptoms), and costochondritis (chest pain)), cervical spine pain (degenerative joint disease), and not to an undiagnosed condition. She has also been diagnosed with chronic endometriosis and perimenopause. For purposes of completeness, the Board has reviewed the Veteran's STRs and post service records. The Veteran's February 1980 report of medical history for "occupational exposure to ionizing radiation" reflects that she reported that she had "terrible sleeping & depression" for six months. A March 27, 1981 STR reflects that the Veteran had complaints of sore throat and increasing fatigue. It was noted that she had been seen in sick call where the CBC was negative for mononucleosis and 10 percent atypical lymphocytes. The Veteran reported she felt "washed out". A CBC one week later revealed 30 percent atypical lymphocyte with negative mono test. The assessment was viral syndrome. It was noted that in "view of 30 % atypical lymphocytes & palpable spleen, a diagnosis of mono cannot be ruled out." A March 30, 1981 STR reflects that the Veteran felt better. The assessment was probable viral syndrome - doubt mono." A September 1981 STR reflects that the Veteran was noted to be developing varicosities below the calves more than one year earlier and it had rapidly increased in number in the past 1-2 months as well as increasingly severe pain. It was noted that she was unable to sleep at night secondary to burning pain. Thus, the record provides a clinical explanation, other than chronic fatigue syndrome, for the Veteran's inability to sleep at night. A February 1983 report of medical history for "occupational exposure to ionizing radiation" reflects that the Veteran reported "I am in good health and taking no medication." She denied frequent trouble sleeping. An August 1986 report of medical history for enlistment purposes reflects that the Veteran denied frequent trouble sleeping. A February 1989 STR reflects that the Veteran had a possible ulcer. She had complaints of recurrent epigastric pain. A March 1989 STR reflects that the Veteran had abdominal pain for 6 weeks which was increased by greasy foods. An April 1989 STR reflects that the Veteran had a lump on her right side which was sore to the touch, and had the consistency of a lipoma. A July 14, 1989 STR reflects that the Veteran had complaints of being lethargic and having body aches, and general malaise. It was noted that she was anorexic, afebrile with no respiratory problems or GI problems. Her symptoms were within normal limits. The assessment was "fatigue syndrome". The Board acknowledges this assessment; however, while the Veteran may have been diagnosed with "fatigue syndrome" in service, the evidence is against a finding that she has had chronic fatigue syndrome post service. A February 1989 STR dental questionnaire reflects that the Veteran denied painful joints. A January 1990 STR reflects that that the Veteran reported a headache for six days, ear aches, body aches, sore throat, nasal and sinus congestion, chills, fever, and generalized aching. Productive cough and extreme malaise and fatigue. The impression was acute viral syndrome, bronchitis, and rule out pneumonia. She was seen on additional dates in January 1990 for follow ups for sinusitis. A February 15, 1990 STR reflects that the Veteran had intermittent chest pain, increasing fatigue, and joint pain; she was assessed with costochondritis. A February 17, 1990 STR reflects that the Veteran reported feeling ill for two weeks. She complained of generalized myalgia and arthralgia, lethargy, and weakness. Upon examination, there was no acute joints or effusion. She was prescribed bed rest and Motrin and to be seen for follow-up the next morning. A February 18, 1990 STR reflects that the Veteran had atypical myalgia, fatigue, and lassitude. She reported pain in all four extremities, but there was no rash, no chills, no fever, and no swollen or tender joints. It was noted that there was a paucity of physical findings or lab data. It was further noted that it could be a viral syndrome or an atypical presentation of rheumatology or neurologic syndrome. A March 1991 STR reflects that the Veteran had a viral syndrome. An October 1991 report of medical history for occupational exposure to ionizing radiation reflects that the Veteran reported "I am presently in good health." She noted numerous complaints to include headaches, cramps, indigestion, broken bones, and a positive PPD test, but denied frequent trouble sleeping. The Veteran's December 1991 report of medical history for separation purposes reflects that the Veteran denied having, or having had, frequent trouble sleeping. The Board finds it notable that the Veteran reported that she had leg cramps associated with phlebitis, indigestion, an allergy, broken toes and fingers, and a dislocated right elbow. The Board finds that if she were experiencing symptoms of chronic fatigue symptoms it would have been reasonable for her to have reported it when she reported her other disabilities; however, she did not. An August 2004 VA examination report is of record. It reflects that the Veteran reported that she was currently employed as a licensed practical nurse at a nursing home where she was working 100 hours a week. The examiner noted that the Veteran "has a responsible job and works many hours of overtime. She also reports that she has taken college courses up to and including last year and has made the dean's list . . . She describes her sleep as restless. She describes herself as fatigued and "tired all day " Again note, she works many hours of overtime." In a May 2004 statement, the Veteran reported that she has a disabled husband and a handicap son and must handle matters for them. A March 2005 record from Malone Internal Medicine, PC reflects that the Veteran reported that she is "feeling extremely fatigued." A June 2005 VA clinical record reflects that the veteran denied a history of present illness (HPI) of fatigue; however, it also notes that she presented for a three month office visit and stated that "she is still having a problem with fatigue. works nights. has only had 6 hours of sleep in 3 days". The Veteran denied joint pain. It was noted that she presented with depression with a gradual onset following job stress. The report reflects that she "appears healthy and well developed." It further reflects that the Veteran reported that she was stressed from her work at a nursing home, and that she reported that "she could not sleep. She only gets two hours of sleep here and two hours of sleep there. She works at night." In a February 2006 VA Form 9, the Veteran stated that it was untrue that she works 100 hours a week; she reported that she works 40 to 50 hours a week. VA records also note that the Veteran has no time for hobbies because she has a "demanding lifestyle." A copy of electronic correspondence from the Veteran dated in March 2005 reflects her opinion that some of her fatigue may be due in part to working the 3rd shift at her job. She also noted that she had a handicap son and was a licensed practical nurse. In sum, the record reflects that during the Veteran's claim, she was employed as a licensed practical nurse during the night shift, working a minimum of 40 hours a week and also overtime. During this time, she also attended college classes and made the Dean's list, and took care of the needs of a disabled family member, all the while getting little sleep. The Board is sympathetic to the Veteran's fatigue, but finds that the evidence of record does not reflect a diagnosis of chronic fatigue syndrome. While the Veteran may have fatigue and may have had fatigue in service, the evidence of record, as noted above, does not support a finding that the Veteran has a current diagnosis of chronic fatigue syndrome in accordance with 38 C.F.R. § 4.88a. The evidence is against a finding of a new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months. In addition, she does not have six or more of the listed symptoms. Notably, while complaining of fatigue, the Veteran was able to work a full time job of at least 40 hours a week and attend college courses. The most probative clinical evidence weighs against a finding of chronic fatigue syndrome. As a service connection claim requires, at a minimum, medical evidence of a current disability, the Veteran's claim for service connection for chronic fatigue syndrome is not warranted in this case. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See also Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997). Entitlement to an initial rating for varicose veins of the right lower extremity, post-phlebitic syndrome, in excess of 20 percent disabling prior to April 25, 2012, and in excess of 40 percent disabling from April 25, 2012 The Veteran's varicose vein disability is rated under DC 7121. Prior to April 25, 2012 The Veteran would be entitled to a rating in excess of 20 percent rating prior to April 25, 2012 if the evidence reflected that she had persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration (40 percent), persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration (60 percent), or massive board-like edema with constant pain at rest (100 percent). A June 18, 2003 record from Dr. C. Richards reflects that the Veteran was seen for painful varicosity leg edema. The record reflects that the Veteran reported that she uses TED hoses and has job where "she is working quite a bit standing on her feet a lot and has some swelling in her legs and lately it has been getting more painful." A June 2005 VA clinical record reflects that the Veteran had no edema of the extremities. A June 2006 VA examination report is of record. It notes that the Veteran had right vein stripping for thrombophlebitis while active duty and "has not had any sequela from that other than subjective report of leg feeling heavy and pitting edema. However, on today's exam she [has] no objective findings." The examiner noted that the Veteran reported that she gets edema daily that she has to wear support hose; however, she was not wearing them on the day of the examination and did not have edema. The examiner noted that there are "no visible venous deformities in areas previously affected. No ulcers edema stasis, pigmentation eczema, or edema." The impression was a normal examination. In a March 2010 written brief presentation, the Veteran's accredited representative stated that the Veteran contends that she wears compression stockings and is therefore, entitled to an increased evaluation. veins The veteran contends she wears compressions A July 2010 VA examination report reflects that the Veteran reported persistence of superficial varicosities and the pain behind the right knee. The symptoms of swelling pain and heaviness persist. It was noted that recently, the Veteran has "developed a discoloration circumferentially over the ankles. While unattractive it in and of itself is asymptomatic. The Veteran has no symptoms of claudication as to suggest arterial insufficiency though the Veteran will get an occasional cramp in the calf muscles." Physical examination revealed bilateral clusters of varicosities in the popliteal area of the right leg and anteriorly medially and laterally in the upper third of both legs. Circumferentially and extending for out 10 centimeters over the right ankle there was a purplish discoloration. There was no skin breakdown and no weepage upon examination, although the Veteran reports such when the legs have been dependent for more protracted periods. The ankles were slightly swollen, the right more than the left. In sum, the evidence of record, as noted above, does not support a finding that the Veteran had persistent edema and stasis pigmentation or eczema. As noted above, she had no objective findings in June 2005 or June 2006 upon examination. The July 2010 report is also negative for persistent stasis pigmentation or eczema. The purple discoloration of the right ankle is indicative of beginning stasis pigmentation, which is compensated in a 20 percent evaluation. While the Veteran is competent to report her symptoms, the Board finds that the objective clinical findings are more probative than the Veteran's complaints made for compensation purposes. From April 25, 2012 The Veteran would be entitled to a rating in excess of 40 percent if the evidence reflected massive board-like edema with constant pain at rest (100 percent) or persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration (60 percent). An April 2012 VA examination report reflects that the Veteran reported aching and fatigue in the left lower extremity after prolonged standing or walking and that such symptoms were relieved by elevation. It also notes that she had persistent stasis pigmentation or eczema and persistent edema. It is negative for a finding of massive board-like edema, constant pain at rest, or ulceration. It also noted that the Veteran did not use any assistance devices as a normal mode of locomotion. The report reflects that the Veteran did not have any scars which were painful or unstable or totaled at least 38 square centimeters in size. It was noted that she had multiple small bluish veins on lateral aspect of the right foot, and 2-3 cm clusters of bluish flat nontender veins in the right popliteal fossa and bilateral lower legs. She had bilateral pitting edema. The report reflects that the Veteran's disability did not impact her ability to work. Thus, the competent credible evidence of record is against a finding of massive board-like edema with constant pain at rest (100 percent) or persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration (60 percent). The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to an initial rating for status post ulnar nerve entrapment of the right wrist in excess of 10 percent disabling prior to August 30, 2005, and in excess of 30 percent disabling from April 25, 2012 The Veteran's nerve entrapment disability of the right wrist is rated under DC 8516. The right upper extremity is considered the Veteran's major or dominant extremity based on the April 2012 VA examination report. A rating in excess of 10 percent would be warranted if the Veteran had moderate (30 percent disabling) or severe (40 percent disabling) incomplete paralysis or completed paralysis (60 percent disabling) of the ulnar nerve. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The Board also observes that the words "mild", "moderate", and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). A February 2006 Lake Placid sports medicine NCS/EMG test result report reflects the following: "Nerve conduction velocity studies were performed in the right upper extremity in the median and ulnar nerve distributions. . . there is electrophysiologic evidence of a very minimal hint of carpal tunnel syndrome and possibly a little bit of impingement of the ulnar nerve at the wrist. . . . There is no evidence of impingement of nerve roots or more proximal injury by EMG testing today." An October 2007 report from Dr. V. Madved reflects that an NCS/EMG test revealed an impression of "moderate medial sensory neuropathy on the right. Moderate right ulnar neuropathy/cubial tunnel syndrome. Mild right carpal tunnel syndrome. Mild left medial sensory neuropathy. Brachial plexopathy and cervical radiculopathy ruled out. A July 2010 VA examination report reflects that the Veteran reported paresthesias and dysesthesias of the right hand from the wrist to the fingertips, and decreased grasp strength. The Veteran did not use any supportive devices. The examiner found that the Veteran had moderate right ulnar nerve entrapment at the wrist based on the 2007 nerve studies. Radial pulses were bilaterally equal and full. The Veteran was able to completely close her fingers to the palmar crease in a fist formation and overlay the thumbs. Dexterity was well demonstrated by opposing the thumb with all of the fingertips in forward and backwards succession. November 2011 VA EMG/NCS results reflect "evidence of mild right ulnar neuropathy at the level of the elbow. This neuropathy is affecting mainly motor fibers. No evidence of radial nerve neuropathy of the right. Evidence of mild bilateral median nerve neuropathy a the level of the wrist (carpal tunnel syndrome). This affecting only sensory fibers." An April 2012 VA examination report reflects that the Veteran reported that she has numbness, tingling, and weakness in the right hand and numbness and tingling in the right medial upper arm. The April 2012 VA examiner noted that the November 2011 Stratton VAMC EMG/NCS ulnar nerve electrodiagnostic findings at the right wrist were normal. Therefore, the Veteran had no symptoms or effects from the right wrist condition. The examiner further noted that the November 2011 results reflected abnormal ulnar nerve electrodiagnostic findings at the elbow and right carpal tunnel syndrome. The right ulnar neuropathy affects sensation and strength in parts of the 3rd, 4th, and 5th digits. The disability affected her ability to work in that she had decreased grip and pinch strength. The examiner noted that the ulnar nerve had incomplete paralysis of moderate severity. In sum, the competent clinical evidence of record reflects that the Veteran had no more than mild incomplete paralysis symptoms prior to October 8, 2007, no more than moderate from October 8, 2007 to November 7, 2011, no more than mild from November 7, 2011 to April 25, 2012, and no more than moderate from April 25, 2012. At no point, did the Veteran's disability equate to severe incomplete paralysis or complete paralysis. As noted in the July 2010 report, she was able to completely close her fingers in a fist. Accordingly, the criteria for a rating for status post ulnar nerve entrapment of the right wrist in excess of 10 percent disabling prior to October 8, 2007 have not been met. The criteria for a rating for status post ulnar nerve entrapment of the right wrist of 30 percent and no higher, from October 8, 2007 to November 7, 2011 have been met. The criteria for a rating for status post ulnar nerve entrapment of the right wrist in excess of 10 percent from November 7, 2011 to April 25, 2012 have not been met. The criteria for a rating for status post ulnar nerve entrapment of the right wrist in excess of 30 percent disabling from April 25, 2012 have not been met. Extraschedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In evaluating the Veteran's service-connected disabilities, the Board has attributed all potentially service-connected symptoms to one service-connected condition or another. See Mittleider v. West, 11 Vet. App. 181 (1998). The discussion above reflects that the symptoms of the Veteran's of her varicose veins of the right lower extremity, post-phlebitic syndrome disability and her ulnar nerve entrapment disability. With regard to her varicose veins, the rating criteria include symptoms of edema, fatigue, statis pigmentation, eczema, ulceration, induration. With regard to the Veteran's ulnar nerve entrapment, the Board again finds that the applicable rating criteria contemplate the Veteran's symptoms. The rating criteria are broad enough to allow for any related symptoms to be considered based on their severity because it allows for the symptoms to be classified as incomplete paralysis on a mild, moderate, or severe basis, or to be classified as complete paralysis. The effects of the Veteran's disabilities have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Thun v. Peake, 22 Vet. App. 111 (2008). The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for chronic fatigue syndrome is denied. Entitlement to an initial rating for varicose veins of the right lower extremity, post-phlebitic syndrome, in excess of 20 percent prior to April 25, 2012 and in excess of 40 percent from April 25, 2012 is denied. Entitlement to an initial rating for status post ulnar nerve entrapment of the right wrist in excess of 10 percent disabling prior to October 8, 2007 is denied. Entitlement to an initial staged rating for post ulnar nerve entrapment of the right wrist of 30 percent and no higher, from October 8, 2007 to November 7, 2011 is granted. Entitlement to an initial staged rating for post ulnar nerve entrapment of the right wrist in excess of 10 percent from November 7, 2011 to April 25, 2012 is denied. Entitlement to an initial staged rating for post ulnar nerve entrapment of the right wrist in excess of 30 percent from April 25, 2012 is denied. REMAND Entitlement to service connection for impingement of a nerve (to include pain in the right arm, shoulder, elbow, and chest) also claimed as thoracic outlet syndrome and bone abnormality of the shoulder blade Entitlement to service connection for a cervical spine disability The claim file includes an April 2012 VA examination report which reflects that the STRs included a January 1987 STR which reflected complaints of "right back pain into right arm, tenderness right scapula, and assessment of musculoskeletal pain right upper back." In addition, a June 1988 STR reflected complaints of "pinched nerve right shoulder, burning under right scapula." Despite initially noting these complaints, the examiner, in the rationale, stated "Review of C file finds no SMR documentation of c/o right shoulder pain, or medical evaluation or diagnosis of a right shoulder condition. No nexus to active duty established." Based on the foregoing, the Board finds that the rationale is inadequate. The rationale should include a discussion of the January 1987 and June 1988 STR. The Board acknowledges that the Veteran's subsequent December 1991 report of medical history for separation purposes reflects that she denied recurrent back pain. In addition, although she checked the block indicating that she had had "painful or 'trick' shoulder or elbow", she clarified that it was her right elbow. Nevertheless, her complaints in 1987 and 1988 should be addressed by the examiner. In addition, the examiner should discuss, in the rationale, the Veteran's 2006 rotator cuff tear, if pertinent (See June 2006 VA examination report). The Board notes that the Veteran has reported symptoms of pain in the right arm, shoulder, elbow, and chest; however, she has already been service-connected for post ulnar nerve entrapment, dislocation of the right ulnar, and costochondritis. The Board finds that, if the clinician finds that the Veteran has a disability casually related to service, a VA opinion which differentiates her reported symptoms between various diagnosed disabilities may be useful to the Board. An October 2007 private record from Dr. V. Medved reflects that the Veteran presented for initial electrodiagnostic evaluation of pain, numbness, and tingling and muscle weakness in right upper extremity and right shoulder. It was noted that it was important to differentiate her symptoms between brachial plexopathy combination of neuropathy median neuropathy pain from shoulder due to extensive surgery and scarring, cervical radiculopathy and other nerve entrapments. In determining whether the Veteran has disability of the shoulder, this should be addressed. Accordingly, the case is REMANDED for the following action: 1. Obtain a supplemental opinion to the April 2012 VA examination report which provides an adequate rationale for the VA examiner's opinion with regard to the issues of entitlement to service connection for impingement of a nerve (to include pain in the right arm, shoulder, elbow, and chest) also claimed as thoracic outlet syndrome and bone abnormality of the shoulder blade, and entitlement to service connection for a cervical spine. The rationale should include consideration of the entire pertinent claims file, and should discuss, if pertinent, the following: a.) the January 20, 1987 STR, b.) June 7, 1988 STR, c.) the December 1991 report of medical history which notes a dislocated right elbow but no shoulder complaints, d.) 2006 records reflecting a rotator cuff tear, and e.) the October 2007 private record by Dr. V. Medved noting various symptoms. If the clinician finds that the Veteran has a disability causally related to service, the clinician should differentiate, if reasonably possible, the Veteran's symptoms which are attributable to the claimed disability(ies) from those attributable to her already service-connected post ulnar nerve entrapment, dislocation of the right ulnar, and costochondritis. 2. After undertaking any other development deemed appropriate, the RO should readjudicate the issues of entitlement to service connection for impingement of a nerve (to include pain in the right arm, shoulder, elbow, and chest) also claimed as thoracic outlet syndrome and bone abnormality of the shoulder blade, and entitlement to service connection for a cervical spine disability. If a benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and her representative with an appropriate opportunity to respond. Thereafter, the matters should be returned to the Board as warranted. The appellant 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs