Citation Nr: 1336159 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 08-06 790A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent for right knee anterior patellar spurs. 2. Entitlement to a rating in excess of 10 percent for right carpal tunnel syndrome. 3. Entitlement to a rating in excess of 10 percent for left carpal tunnel syndrome. 4. Entitlement to service connection for a right hand arthritis, to include as secondary to the service-connected right carpal tunnel syndrome. 5. Entitlement to service connection for left hand arthritis, to include as secondary to the service-connected left carpal tunnel syndrome. 6. Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD). 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1967, from February 1969 to February 1971, and from December 1976 to January 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. No hearing was requested. In March 2012, inter alia, the Board remanded the Veteran's claims under consideration herein. In a May 2013 rating decision, the Appeals Management Center (AMC) increased the Veteran's disability rating for his service-connected right knee anterior patellar spurs to 10 percent effective October 18, 2005. After the Veteran has perfected his appeal, a subsequent rating decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35 (1993). Accordingly, the issue is still properly before the Board here and the issue has been appropriately rephrased above. Furthermore, in a May 2013 supplemental statement of the case, the AMC denied the Veteran a disability rating in excess of 10 percent for the right knee anterior patellar spurs and continued the denial of the Veteran's increased rating claims for his right and left carpal tunnel syndrome as well as his service connection claims for right and left hand arthritis. The Veteran's VA claims folder has been returned to the Board for further appellate proceedings. The Board also notes that the May 2013 rating decision granted the Veteran a separate evaluation for right knee subluxation and assigned a 10 percent disability rating effective March 27, 2013. As evidenced by the claims folder, the Veteran has not expressed disagreement with either the assigned disability rating or effective date. Accordingly, that issue is not in appellate status and will be discussed no further herein. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) [pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA]. The Board informs the Veteran that should he desire to appeal either the assigned disability rating or effective date of the right knee subluxation disability, he must do so within one year from the date the May 2013 rating decision was mailed. 38 C.F.R. § 20.302 (2012). The Board further notes that in a January 2013 rating decision, the AMC granted the Veteran's claim of entitlement to service connection for PTSD. Moreover, in the above-referenced May 2013 rating decision, the AMC granted the Veteran's claim of entitlement to service connection for a left knee disability, specifically left knee subluxation, to include as secondary to the right knee disability. In view of the foregoing, these issues have been resolved and are no longer before the Board. See generally Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997). The Board observes that in an August 2013 statement, the Veteran requested "retroactive pay" as well as an explanation of his assigned disability ratings. To the extent that these statements indicate a claim for an earlier effective date or increased rating claim, the agency of original jurisdiction (AOJ) should obtain clarification from the Veteran as to these matters. The Board notes that the Veteran was previously represented in this appeal by The American Legion, including when this matter was previously remanded by the Board in March 2012. However, the Veteran submitted a written statement in August 2013 expressing his desire to have The American Legion "be taken off" as his representative. Thus, the Veteran is no longer represented by The American Legion in this case. The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. The issues of entitlement to service connection for arthritis of the right and left hands as well as for an acquired psychiatric disorder other than PTSD and entitlement to TDIU 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 Veteran's service-connected right knee anterior patellar spurs is currently manifested by pain and minimal limitation of motion as well as an asymptomatic post-surgical scar; the evidence does not show flexion limited to 45 degrees or less; extension limited to 10 degrees or more; locking; ankylosis; or impairment of the tibia and fibula associated with the Veteran's right knee. 2. The Veteran's right carpal tunnel syndrome is manifested by no more than mild incomplete nerve paralysis. 3. The Veteran's left carpal tunnel syndrome is manifested by no more than mild incomplete nerve paralysis. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating in excess of the currently assigned 10 percent for the service-connected right knee anterior patellar spurs have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261 (2013). 2. The criteria for a disability rating in excess of 10 percent for right carpal tunnel syndrome have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). 3. The criteria for a disability rating in excess of 10 percent for left carpal tunnel syndrome have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to increased disability ratings for his service-connected right knee anterior patellar spurs and right and left carpal tunnel syndrome. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, in March 2012, the Board remanded these claims and ordered the either the AOJ or AMC to schedule the Veteran for VA examinations for his right knee disability and right and left carpal tunnel syndrome. The Veteran's claims were then to be readjudicated. Pursuant to the Board's remand instructions, the Veteran was afforded VA examinations for his right knee disability and right and left carpal tunnel syndrome in June 2012 and March 2013, and reports of the examinations were associated with his claims folder. The Veteran's claims were thereafter readjudicated via the May 2013 SSOC. Accordingly, the Board's remand instructions have been complied with regard to the Veteran's right knee and right and left carpal tunnel claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice, to include notice with respect to the disability rating and effective-date elements of the claim, by a letter mailed in October 2006, prior to the initial adjudication of his claims. In short, the record indicates the Veteran received appropriate notice pursuant to the VCAA. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes the Veteran's statements, service treatment records, as well as VA and private treatment records. The Veteran was afforded VA examinations in June 2012 and March 2013. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, reviewed his claims folder, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's right knee disability and right and left carpal tunnel syndrome under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2013); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2013). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. In his March 2008 substantive appeal [VA Form 9], the Veteran declined the option of testifying at a personal hearing. Accordingly, the Board will proceed to a decision as to the issues of entitlement to increased disability ratings for right knee anterior patellar spurs and right and left carpal tunnel syndrome. Higher evaluation for right knee anterior patellar spurs Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2013). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2013). 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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). A request for an increased rating must be viewed in light of the entire relevant medical history. See 38 C.F.R. § 4.1 (2013); see also Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). However, where entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held 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." The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10 (2013). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40 (2013). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2013). The Veteran seeks entitlement to an increased rating for his service-connected right knee anterior patellar spurs, which is currently evaluated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5260 [limitation of leg flexion]. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Code 5257 contemplates recurrent subluxation or lateral instability of the knee. As discussed above, the Veteran was awarded a separate 10 percent rating for right knee subluxation under Diagnostic Code 5257 in the May 2013 rating decision effective March 27, 2013 and he has not disagreed with either the assigned disability rating or effective date. The Board additionally notes that there is no evidence of ankylosis, locking of the knee, disability caused by cartilage removal, or malunion or nonunion of the tibia and fibula. Thus, Diagnostic Codes 5256, 5258, 5259, and 5262 do not apply in this case. The medical evidence of record demonstrates that the Veteran's right knee disability is manifested by joint pain and limited range of motion. This symptomatology is congruent with the criteria set out in Diagnostic Codes 5260 [limitation of flexion] and 5261 [limitation of extension]. Accordingly, the Board finds that rating the Veteran under Diagnostic Codes 5260 and 5261 is appropriate in this case. Moreover, a veteran may receive separate ratings for limitations in both flexion and extension under Diagnostic Codes 5260 and 5261. See VAOPGCPREC 9-2004. Arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). The medical evidence of record indicates a diagnosis of anterior patellar spurs of the right knee which has been linked to osteoarthritis. See an addendum to the March 2013 VA examination report. As such, because the evidence of record indicates arthritis of the Veteran's right knee, the Board finds that Diagnostic Code 5003 [arthritis], with further consideration of Diagnostic Codes 5260 and 5261 [limitation of leg motion], are for application. Under 38 C.F.R. § 4.71a, Diagnostic Codes 5003, arthritis of a major joint is to be rated under the criteria for limitation of motion of the affected joint. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). For the purpose of rating disabilities due to arthritis, the knee is considered a major joint. See 38 C.F.R. § 4.45 (2013). Where limitation of motion of the joint is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Under Diagnostic Code 5260, limitation of flexion of the leg provides a noncompensable rating if flexion is limited to 60 degrees, a 10 percent rating where flexion is limited to 45 degrees, a 20 percent rating where flexion is limited to 30 degrees, and a maximum 30 percent rating if flexion is limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg provides a noncompensable rating if extension is limited to five degrees, a 10 percent rating if limited to 10 degrees, a 20 percent rating if limited to 15 degrees, a 30 percent rating if limited to 20 degrees, a 40 percent rating if limited to 30 degrees, and a 50 percent rating if limited to 45 degrees. The Board notes that the Veteran has received treatment for his right knee disability on multiple occasions throughout the course of the appeal. Specifically, he reported knee pain when receiving VA treatment in July and October 2005 as well as when receiving private treatment from E.Q., M.D. in November 2006 and May 2007. A July 2006 VA treatment evaluation noted his complaints of pain when walking and upon examination of the right knee, full extension and 120 degrees flexion. An MRI of the right knee dated May 2011 revealed an impression of profound edema in the medial femoral condyle, small to moderate joint effusion, and no meniscal tear. A June 2011 evaluation by B.H., M.D., noted full range of motion of the knee as well as no effusion or tenderness. Dr. B.H. also reported that the Veteran was fully ambulatory without any restrictions, and he was able lift his daughter up, walk up and down stairs, and lift some heavy boxes. The Veteran was afforded a VA examination in June 2012. He complained of chronic constant pain in his knee as well as flare-ups. He did not use assistive devices at that time. He reported that he was not able to walk longer than 15 minutes without having to stop and rest due to the pain in his knee. Upon examination, range of motion testing revealed flexion to 140 degrees with pain at 130 degrees and extension ending at zero degrees with pain at 45 degrees. The Veteran was able to perform repetitive-use testing with three repetitions with post-test flexion to 140 degrees and extension at zero degrees. The Veteran therefore did not have additional loss of range of motion after repetitive-use testing. However, the examiner noted functional loss manifested by less movement than normal and pain on movement. The Veteran did not have tenderness or pain to palpation for the joint line or soft tissues. Flexion and extension muscle strength testing was 4/5. The examiner further noted that the Veteran did not have shin splints. The Veteran was provided a subsequent VA examination in March 2013. He continued his complaints of constant, severe, sharp to throbbing pain in his knee that was aggravated by walking and cold weather. The condition was alleviated with hot showers, elevating the leg, and taking medication. He did not report flare-ups. He used a walker for ambulation. Upon examination, range of motion testing revealed flexion to 110 degrees with pain at 110 degrees and extension to zero degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions with flexion to 110 degrees and extension to zero degrees. The examiner also indicated functional loss which was manifested by less movement than normal, weakened movement, and pain on movement. The Veteran did not have tenderness or pain to palpation for joint line or soft tissues of the knee. Muscle strength testing revealed knee flexion and extension of 5/5. Anterior and posterior as well as medial-lateral instability testing was normal. The examiner noted the absence of shin splints. The examiner also reported that the Veteran had arthroscopic surgery in 1980. Diagnostic Code 5260 contemplates a noncompensable evaluation where there is limitation of knee flexion to 60 degrees, which is exceeded by the 130 degrees and 110 degrees of the right knee taking into account reports of pain recorded during the course of this appeal. There is no evidence which indicates that a greater limitation of flexion currently exists. Thus, without evidence of limitation of flexion of 60 degrees or less in the right knee, a separate compensable evaluation for right knee flexion cannot be assigned based on Diagnostic Code 5260 during any period under consideration. Diagnostic Code 5261 contemplates a noncompensable evaluation with a limitation of knee extension to 5 degrees. Although the June 2012 VA examiner indicated 45 degrees extension with consideration of pain, this finding is at odds with his previous finding of zero degrees extension without consideration of pain. He also reported that repetitive-use testing with three repetitions revealed no additional loss of extension. Furthermore, the subsequent March 2013 VA examination revealed extension to zero degrees with consideration of pain. The July 2006 VA evaluation also indicated full extension as did the June 2011 evaluation by Dr. B.H. which noted full range of motion. Additionally, there is no other competent and probative evidence indicating a greater limitation of extension. As such, the Board finds that the June 2012 VA examiner's finding of 45 degrees limitation of extension with consideration of pain is incongruent with the remainder of the competent and probative evidence of record and is therefore of no probative value in evaluating the Veteran's claim. Thus, without limitation of extension to 10 degrees or more in the right knee, a separate compensable evaluation for right knee extension cannot be assigned under Diagnostic Code 5261 during any period under consideration. For the reasons stated above, under Diagnostic Codes 5260 and 5261, respectively, the limitation of right knee movement exhibited by the Veteran is not so significantly impaired or limited as to indicate a compensable evaluation under either Diagnostic Code for either knee. Where X-ray evidence of arthritis is presented, but the loss of range of motion is noncompensable, a 10 percent disability rating will be assigned under Diagnostic Code 5003. So it is in this case. Further, a rating in excess of 10 percent contemplates X-ray evidence of involvement of two or more minor joint groups, with occasional incapacitating exacerbations. This case, however, involves only one major joint (the right knee). Accordingly, an increased disability rating is not warranted for arthritis. In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. § 4.40 and 4.45 (2013). See DeLuca, supra. The Board recognizes the Veteran's complaints of functional loss as a result of his right knee disability, notably his difficulty in walking for long periods of time as well as flare-ups. However, the Board places greater probative value on the objective clinical findings which do not support a rating in excess of 10 percent. In this regard, the competent medical evidence of record does not indicate any significant functional loss attributed to the Veteran's knee complaints sufficient to warrant a higher disability rating. Specifically, during the VA examination in March 2013, the Veteran was able to maintain right knee forward flexion up to 110 degrees, and right knee limitation of extension of zero degrees when pain was considered. There was no increase in loss of range of motion upon repetitive-use testing. The June 2012 VA examination indicates similar findings with regard to flexion, and as discussed above, the Board finds that the 45 degrees limitation of extension noted by the VA examiner is of no probative value. In light of the fact that the Veteran has repeatedly demonstrated nearly full flexion and normal extension, the Board is satisfied that any additional functional impairment occurring during flare ups would not be sufficient to establish his entitlement to a compensable rating for either limitation of extension or limitation of flexion. Based on this record, the Board is unable to identify any clinical findings that would warrant an evaluation in excess of 10 percent for the Veteran's right knee disability under 38 C.F.R. § 4.40 and 4.45 during the period under consideration. Moreover, in assigning the Veteran a 10 percent rating for his right knee disability, the AMC contemplated functional loss due to the right knee disability. The current 10 percent rating therefore adequately compensates the Veteran for any functional impairment attributable to his service-connected right knee disability. See 38 C.F.R. §§ 4.41, 4.10 (2013). In sum, the Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran's service-connected right knee anterior patellar spurs. In Hart, supra, the Court held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. In reaching its conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that timeframe. See 38 U.S.C.A. § 5110 (West 2002). After a careful review of the record, the Board can find no evidence to support a finding that the Veteran's right knee disability was more or less severe during the appeal period. Specifically, as discussed above, the June 2012 and March 2013 VA examination reports, as well as VA and private treatment records, indicate that the Veteran's right knee symptomatology remained relatively consistent throughout the period. As such, there is no basis for awarding the Veteran an increased disability rating for any time during the period under consideration. Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2013); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14 (2013); see also Fanning v. Brown, 4 Vet. App. 225 (1993). The report of the VA examiner in the March 2013 report indicates that there is a scar on the Veteran's right knee which is consistent with the Veteran's reported surgical history. The applicable rating criteria for skin disorders under 38 C.F.R. § 4.118 were amended, effective August 30, 2002 [see 67 Fed. Reg. 49490-99 (July 31, 2002)] and again in October 2008. The October 2008 revisions are applicable to claims for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his claim in September 2006. Therefore, only the post-2002 and pre-October 2008 schedular criteria is applicable. Under 38 C.F.R. § 4.118, Diagnostic Code 7801, a 10 percent rating of scars is warranted for scars, other than on the head, face, or neck, that are deep or that cause limited motion and have an area or areas exceeding 6 square inches (39 sq. cm.). Under 38 C.F.R. § 4.118, Diagnostic Code 7802, a 10 percent rating is warranted for a scar, other than on the head, face, or neck, that is superficial and does not cause limited motion and has an area or areas exceeding 144 square inches (929 sq. cm.) or greater. A "superficial" scar is one not associated with underlying soft tissue damage. Under 38 C.F.R. § 4.118, Diagnostic Code 7803, a 10 percent rating is warranted for scars that are superficial and unstable. An "unstable" scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Further, under 38 C.F.R. § 4.118, Diagnostic Code 7804, a 10 percent rating of scars is warranted for scars which are superficial and painful on examination. In this case, the Veteran's right knee scar has not been reported as painful, unstable or interfered with range of motion. Moreover, it has been measured at less than 39 square cm. See the March 2013 VA examination report. There is no competent and probative evidence to the contrary. Accordingly, the Board finds that the competent and probative evidence demonstrates that the right knee scar is asymptomatic; a separate rating for the scar under any of the Diagnostic Codes pertaining to scars is not warranted by the evidence of record as they are not applicable to this case. Higher evaluation for right and left carpal tunnel syndrome The law and regulations pertaining generally to disability ratings have been set forth above and will not be repeated here. The Veteran's service-connected right and left carpal tunnel syndrome have been rated under Diagnostic Code 8515, with each assigned a 10 percent disability rating. The Board notes that the Veteran is right-hand dominant (major hand). See, e.g., the March 2013 VA examination report. Diagnostic Code 8515 relates to impairment of the median nerve and provides that a 10 percent disability evaluation is assigned for mild, incomplete paralysis of the median nerve of the minor or major hand. Moderate incomplete paralysis of the major hand warrants a 30 percent evaluation. Moderate incomplete paralysis of the minor hand warrants a 20 percent evaluation. Severe incomplete paralysis of the major hand warrants a 50 percent evaluation. Severe incomplete paralysis of the minor hand warrants a 30 percent evaluation. Complete paralysis of the major hand warrants a 70 percent evaluation. Complete paralysis of the minor hand warrants a 60 percent evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8515. 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, atrophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. 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 or 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. 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 times 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. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2013). A VA treatment record dated July 2006 documents the Veteran's complaints of bilateral hand pain. Neurological examination at that time revealed normal strength in the right and left upper extremities with the exception of mild, symmetrically decreased grip strength. A July 2007 VA treatment record documents the Veteran's treatment for pain and stiffness in his right hand. At that time, Tinel's testing was positive for the right hand and negative for the left hand. Furthermore, painful loss of motion and strength were noted for the right upper extremity. He was instructed to use cold packs and massage his right hand and fingers and was also fitted with an edema glove. A private treatment record dated August 2007 from N.V., M.D., notes that the Veteran's radiculopathy in his right upper extremity had resolved, and he had achiness in his hand which was rheumatoid in nature. Upon examination, the Veteran had normal strength, sensation, and reflexes. The Veteran was afforded a VA hands and peripheral nerves examination in June 2012. He complained of pain in his hands with decreased range of motion and strength. He was also not able to pick up his grandchildren or do yard work due to pain in his hands. However, he did not report flare-ups. He did not use assistive devices for the right and left carpal tunnel syndrome. Upon examination, the VA examiner did not identify paresthesias or dysesthesias, muscle atrophy, or trophic changes. Elbow flexion and extension as well as wrist flexion and extension were 5/5. Grip strength and pinch (thumb to index finger) was 2/5 in the right hand and 3/5 in the left hand. Reflex and sensory examination were normal. The examiner indicated that the Veteran's upper extremities were manifested by normal incomplete paralysis with no functional loss. He also noted limitation of motion in the right long finger. There was also a gap between the right long finger and palm and the left index finger and palm of one inch or more with painful motion beginning at a gap of less than one inch. Right long finger extension was limited by no more than 30 degrees with painful motion beginning at extension of no more than 30 degrees. The Veteran was able to perform repetitive-use testing with three repetitions with no additional limitation of motion for any fingers. The examiner noted functional loss of the fingers or thumbs which was manifested by less movement than normal, weakened movement, and pain in the thumbs and fingers. The Veteran also had pain on palpation. The Board notes that a VA treatment record dated December 2012 documents the Veteran's continued complaints of constant aching and burning pain in his hands which was exacerbated by movement and activities of daily living. Neurological examination indicated that the Veteran was alert and oriented times three and he was able to make full fists. The Veteran was provided a subsequent VA examination in March 2013. He reported severe pain, parathesias and/or dyesthesias, and numbness in his right upper extremity but none of these in his left upper extremity. He also reported that he is not able to reach above his head due to the nerve condition. He did not use any assistive devices for the carpal tunnel syndrome and did not report flare-ups of either hand. Upon examination, muscle strength testing, to include elbow flexion, elbow extension, wrist flexion, wrist extension, and pinch (thumb to index finger) was recorded 5/5 in the right and left upper extremity. However, grip strength was record 4/5 in each hand. The examiner noted that the Veteran did not have muscle atrophy. Reflex and sensory examination of the upper extremities was normal. Furthermore, the Veteran did not have trophic changes, and his gait was normal. The examiner reported that the Veteran's right medial nerve was manifested by incomplete paralysis that was mild in nature, and that his left median nerve was normal. The examiner further reported that electromyography (EMG) study of the right upper extremity was abnormal and revealed mild right median neuropathy. EMG study of the left upper extremity was normal. The examiner also reported that there was no limitation of motion or evidence of painful motion for any fingers or thumbs. However, the Veteran had functional loss of the right and left thumbs and fingers which was manifested by less movement than normal, weakened movement, and pain on movement. In order to receive a higher disability rating, the evidence would need to reflect that the Veteran's service-connected right and left carpal tunnel syndrome was moderate. The Board finds that, based on the evidence of record, the Veteran's service-connected right and left carpal tunnel syndrome do not warrant higher disability ratings. The evidence reflects that while the Veteran endorsed pain and numbness due to the right and left carpal tunnel syndrome, his symptomatology approximates mild impairment in both extremities. In particular, the July 2006 VA treatment record noted his grip strength in both hands as mild. Furthermore, the private treatment record from Dr. N.V. dated August 2007 indicated normal strength, sensation, and reflexes. Although he evidenced decreased grip strength during the June 2012 VA examination as well as decreased range of motion in the right long finger and left index finger, reflex and sensory examinations were normal, and the examiner reported that the upper extremities were manifested by normal incomplete paralysis. Moreover, the December 2012 VA treatment record noted that the Veteran was able to make full fists. Finally, the March 2013 VA examiner indicated mild incomplete paralysis of the right median nerve and normal left median nerve based on EMG study as well as normal reflex and sensory examinations and no limitation of motion or evidence of painful motion for any fingers or thumbs. Accordingly, the Board finds that the disability picture presented by the Veteran's right and left carpal tunnel syndrome is mild, and does not more nearly approximate the criteria for a higher rating in either extremity. 38 C.F.R. § 4.7. The Board has considered other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. at 595. However, there are no other Diagnostic Codes pertaining to the Veteran's symptoms that offer a higher disability rating for the symptoms described in the record. Extraschedular consideration In evaluating the severity of his service-connected disabilities, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disability at issue on an extra-schedular basis. 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). According to the regulation, 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) (2013). 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). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability, with the established criteria shows that the rating criteria reasonably describe the level and symptomatology thereof. The criteria specifically provide for evaluation of the disability based upon impairment of the knee and median nerves and the associated symptomatology, and they practicably represent the average impairment in earning capacity resulting from the Veteran's service-connected disabilities. See 38 C.F.R. § 4.1. ORDER Entitlement to a rating in excess of 10 percent for right knee anterior patellar spurs is denied. Entitlement to a rating in excess of 10 percent for right carpal tunnel syndrome is denied. Entitlement to a rating in excess of 10 percent for left carpal tunnel syndrome is denied. REMAND Service connection for right and left hand arthritis The Board remanded the case in March 2012, in part, for the Veteran to be afforded a VA examination in order to determine whether his arthritis of the right and left hand are related to his military service, or alternatively, his service-connected right and left carpal tunnel syndrome. Unfortunately, the Board finds that an additional remand is necessary prior to review of the Veteran's claims. In conjunction with the prior remand, the Veteran was afforded a VA examination in March 2013. In an addendum dated April 2013, the VA examiner opined that it is less likely than not that the Veteran's diagnosed arthritis of the right and left hands are caused or aggravated by his service-connected right and left hand carpal tunnel syndrome. The examiner's rationale for his conclusion was based on his review of medical literature which stated the following: Bones have a protective covering on each end which prevents the ends of the bones at the joint from grinding together. Additionally, there is a sac filled with fluid between the bones. Arthritis describes a condition in which this protective covering and fluid-filled sac degenerate, allowing bones to rub together. This degeneration may be caused by repetitive use or by disease... The examiner also opined that it is at least as likely as not that the Veteran's degenerative joint disease of the right and left hands was incurred or aggravated as a result of his military service. The examiner's rationale for his conclusion was based on the Veteran's statement that he first "started to have bilateral knee and leg pain in 1970 while stationed in [Vietnam]. Also [the Veteran] injured [his] right knee prior to service playing football." There is no other rationale provided for the VA examiner's conclusion. Indeed, it is unclear as to why the examiner concluded that the Veteran's arthritis of his hands is related to service when only the Veteran's knees and legs were discussed in the rationale. As such, the Board finds that the examiner's opinion as to whether the Veteran's arthritis of the right and left hands are related to his military service is inadequate for evaluation purposes. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) [the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence]. In light of the inadequate opinion provided by the March 2013 VA examiner with regard to whether the Veteran's arthritis of the right and left hand are related to his military service, the AMC obtained an opinion as to the etiology of the Veteran's arthritis of his right and left hands from J.M., M.D., who is one of their staff physicians. After review of the Veteran's claims folder and consideration of his medical history, Dr. J.M. opined that it is less likely than not that the Veteran's arthritis of his right and left hands are related to his military service. Dr. J.M.'s rationale for his conclusion was based on his review of the Veteran's hand X-rays during his active duty which were normal. Although he noted an April 1986 service treatment record for left carpal tunnel release which documented "much incisional pain and decreased range of motion, increased sensitivity and mottled color today" and possible development of "early reflex sympathetic dystrophy," he reported that there was no indication that this condition persisted after physical therapy. Furthermore, this was the only non-carpal tunnel syndrome related hand symptoms the Veteran complained of or was evaluated for while on active duty. The Board finds that the opinion rendered by Dr. J.M. is of no probative value in the evaluation of the Veteran's claim. Crucially, Dr. J.M. is a staff physician of the AMC. However, the Board indicated in the March 2012 remand that an opinion was to be obtained from a VA medical center. Moreover, if the medical evidence of record is insufficient, or, in the opinion of the AMC, of doubtful weight or credibility, the AMC is always free to supplement the record by seeking an advisory opinion or ordering a medical examination in its decisions that clearly support its ultimate conclusions. In light of the foregoing, the Board finds that a supplemental opinion must be obtained as to whether the Veteran's arthritis of the right and left hands are related to his military service as instructed in the prior remand. See Stegall v. West, 11 Vet. App. 268, 270 (1998) (holding that a remand by the Board imposes upon the Secretary of the VA a concomitant duty to ensure compliance with the terms of the remand). Service connection for an acquired psychiatric disorder other than PTSD The Board remanded the case in March 2012, in part, for the Veteran to be afforded a VA examination in order to determine whether he had an acquired psychiatric disorder, to include PTSD, that is related to his military service and to also obtain outstanding treatment records. The Board characterized the Veteran's claim as an acquired psychiatric disorder as a review of the Veteran's service treatment records reflected a report of treatment for depression or anxiety in a December 1982 reenlistment examination. Thereafter, during his December 1987 retirement examination, the Veteran reported having frequent trouble sleeping, depression or excessive worry, loss of memory or amnesia, and nervous trouble. Moreover, the Veteran had reported mental health symptoms since his service in Vietnam. See, e.g., an August 2000 VA treatment record (recording that the Veteran was coping with his PTSD symptoms for some time until 1999, diagnosing major depressive disorder with panic attacks and exacerbation of PTSD). The Veteran's claim of entitlement to service connection for an acquired psychiatric disorder was to be readjudicated following the VA examination. Pursuant to the March 2012 remand, the Veteran was afforded a VA psychological examination in December 2012 and outstanding treatment records were obtained as to his acquired psychiatric disorder. Thereafter, as discussed above, the Veteran was granted entitlement to service connection for PTSD by the AMC in the January 2013 rating decision. However, the AMC did not adjudicate the Veteran's claim of entitlement to an acquired psychiatric disorder other than PTSD as instructed by the Board in the March 2012 remand. Accordingly, the Board finds that remand is warranted for adjudication of the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder other than PTSD in compliance with the March 2012 remand. See Stegall, supra. TDIU The Board observes that in a memorandum dated January 2013, the AMC indicated that the Veteran raised an issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). This issue has not yet been adjudicated by the AOJ. The Board further notes that the evidence of record indicates that the Veteran's service-connected disabilities, to include his right knee disability and right and left carpal tunnel syndrome, affect his employability inasmuch that he has difficulty grasping objects and walking. See, e.g., VA examination reports for the Veteran's right knee disability and right and left carpal tunnel syndrome dated May 2013. In this regard, the Board finds that the issue of TDIU has been raised. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (Once a veteran submits evidence of medical disability and additionally submits evidence of unemployability, VA must consider total rating for compensation based upon individual unemployability). The U.S. Court of Appeals for Veterans Claims held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). If the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted. Id. at 455. Accordingly, the matter should be remanded for adjudication of the Veteran's claim for the issue of TDIU, in accordance with the holding in Rice. Accordingly, the case is REMANDED for the following action: 1. Issue a VCAA notice letter which satisfies all VCAA notice obligations with regard to the issue of entitlement to TDIU, in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002); 38 C.F.R. § 3.159; Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); and any other applicable legal precedent. This notice letter should specifically apprise the Veteran of the evidence and information necessary to substantiate his claim for TDIU. Also, inform the Veteran of the division of responsibility between him and VA in producing or obtaining that evidence or information. The letter should include an explanation as to the information or evidence needed to establish a disability rating and an effective date in the event of award of the benefit sought, as outlined by the Court in Dingess/Hartman. 2. Refer the case to the examiner who provided the March 2013 VA examination for the Veteran's arthritis of the right and left hands. The claims folder must be made available to and reviewed by the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (probability of 50% or more) that the Veteran's arthritis of the right and/or left hand was incurred or aggravated as a result of his military service. All available lay and medical evidence should be considered. If an opinion cannot be provided without further examination of the Veteran, such an examination must be provided. The rationale for all opinions expressed must be provided. The report prepared must be typed. 3. The Veteran should be scheduled for an appropriate VA examination to determine whether his service-connected disabilities prevent him from securing and following substantially gainful occupation. All indicated tests and studies are to be performed. Prior to the examination, the claims folder must be made available for review of the case. A notation to the effect that this record review took place should be included in the report. Opinions should be provided based on the results of examination, a review of the medical evidence of record, and sound medical principles. All examination findings, along with the complete rationale for all opinions expressed, should be set forth in the examination report. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the Veteran's claims of entitlement to service connection for arthritis of the right and left hands as well as an acquired psychiatric disorder other than PTSD and entitlement to TDIU must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See 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 A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs