Citation Nr: 1336737 Decision Date: 11/12/13 Archive Date: 11/22/13 DOCKET NO. 07-25 317 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for retropatellar pain syndrome of the right knee. 2. Entitlement to an evaluation in excess of 10 percent for retropatellar pain syndrome of the left knee. 3. Entitlement to an evaluation in excess of 10 percent for left carpal tunnel syndrome for the period prior to November 26, 2010, and to an evaluation in excess of 20 percent for the period from November 26, 2010. 4. Entitlement to service connection for nasal scar residuals, status post rhinoplasty with septoplasty and cartilage graft. 5. Entitlement to service connection for residuals, other than nasal scars, status post rhinoplasty with septoplasty and cartilage graft. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Kordich, Senior Counsel INTRODUCTION The Veteran had active duty service from April 1983 to February 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March and June 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which denied entitlement to service connection for status post rhinoplasty with septoplasty and cartilage graft, granted separate 10 percent disability evaluations respectively for left and right knee retropatellar pain syndromes effective March 1, 2004, and continued the Veteran's 10 percent disability evaluation for his left carpal tunnel syndrome. By a rating decision dated April 7, 2011, the Veteran's disability evaluation for left carpal tunnel syndrome was increased to 20 percent disabling effective November 26, 2010, the date of a VA examination showing increased severity. In the decision below, service connection for nasal scars as part of the broader claim seeking compensation for residuals of the status post rhinoplasty with septoplasty and cartilage graft is being granted. The Board remanded the case in April 2013 for an examination and opinion concerning all of the residuals of the status post rhinoplasty with septoplasty and cartilage graft. Unfortunately, the examiner did not adequately identify any residuals other than nasal scars. Therefore, the Board has recharacterized the issues on appeal as set forth on the title page. In September 2012, the Veteran testified before the undersigned at a Travel Board hearing held at the San Antonio satellite office of the Houston RO. A transcript has been incorporated into the record. In an April 2013 decision, the Board remanded the case for further development to include VA examination and obtaining outstanding treatment records. The United States Court of Appeals for Veterans Claims (Court) has held that a claim for TDIU is part of a claim for higher rating when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). The record reflects that the Veteran may be unemployable due to his service-connected disabilities. Thus, TDIU claim is part of his claims for increased ratings currently before the Board and must be adjudicated. The issues of entitlement to service connection for residuals, other than nasal scars, status post rhinoplasty with septoplasty and cartilage graft and 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. Retropatellar pain syndrome of the right knee is manifested by flexion to 120 degrees and extension to 0 degrees with pain during ranges of motion, but with no additional loss of function due to factors such as pain or weakness. 2. Retropatellar pain syndrome of the left knee is manifested by flexion to 120 degrees and extension to 0 degrees with pain during ranges of motion, but with no additional loss of function due to factors such as pain or weakness. 3. Prior to November 26, 2010, the Veteran's service-connected carpal tunnel syndrome of the left wrist was not manifested by symptomatology more nearly approximating at least moderate incomplete paralysis of the median nerve. 4. From November 26, 2010, the Veteran's service-connected carpal tunnel syndrome of the left wrist has not been manifested by symptomatology more nearly approximating at least severe incomplete paralysis of the median nerve. 5. The Veteran's rhinoplasty with septoplasty and cartilage graft in service resulted in nasal surgical scars over the left nasal area and over the nasal columella area. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for retropatellar pain syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5014, 5260, 5261 (2013). 2. The criteria for an initial rating in excess of 10 percent for retropatellar pain syndrome of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5014, 5260, 5261 (2013). 3. Prior to November 26, 2010, the criteria for an evaluation in excess of 10 percent for carpal tunnel syndrome of the left wrist have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.14, 4.7, 4.124a, Diagnostic Code 8615 (2013). 4. From November 26, 2010, the criteria for an evaluation in excess of 20 percent for carpal tunnel syndrome of the left wrist have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.14, 4.7, 4.124a, Diagnostic Code 8615 (2013). 5. The criteria for service connection for nasal scar residuals, status post rhinoplasty with septoplasty and cartilage graft, have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2013)) include enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims(s); (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirement applies to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Dingess/Hartman also held that in rating cases, a claimant must be informed of the rating formula for all possible schedular ratings for an applicable rating code, and that VA must provide information regarding the effective date that may be assigned. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Sec'y of Veterans Aff., 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in April 2006, January 2007 and December 2010 pre-rating letters, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the increased ratings claims, and the service connection claim, as well as what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. These letters also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The June 2006 rating decision was the initial adjudication of the claim for service connection and for an increased rating issue for carpal tunnel syndrome. Hence, the April 2006, January 2007, and December 2010 letters, which meet the content of notice requirements described in Dingess/Hartman and Pelegrini, also meet the VCAA's timing of notice requirement. In this appeal, in a November 2003 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim of entitlement to service connection for the bilateral knee disabilities, as well as what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The November 2003 letter did not include adequate notice of how the effective date for any increased disability rating for the bilateral knee disabilities on appeal would be assigned. During the pendency of the appeal, the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date for the award of benefits will be assigned, if service connection is awarded. Dingess/Hartman supra. Although the November 2003 letter did not provide adequate notice consistent with Dingess/Hartman, the Veteran received additional notice in January 2007 pertaining to the downstream disability rating and effective date elements of his bilateral knee disability claims. The record shows that the claims were thereafter readjudicated in a statement of the case and in supplemental statements of the case. Despite initially inadequate notice, the Board finds no prejudice to the appellant in proceeding with the issuance of decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the claim as to the knee was substantiated once service connection was granted. In addition, the RO did eventually provide adequate notice, followed by readjudication of the claim. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters on appeal. Pertinent medical evidence associated with the claims file consists of VA treatment records and the reports of January 2007, November 2010, March and June 2011, and June 2013 examinations. The Board has reviewed the reports of those examinations, and finds that they are adequate for adjudicating the issues on appeal. An April 2013 Board remand requested that the RO obtain certain private medical records the Veteran references at his September 2012 Travel Board hearing; the record reflects that those records have been obtained. Also of record and considered in connection with the appeal is the transcript of the Veteran's September 2012 Travel Board hearing. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices from the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of any of the matters herein decided, at this juncture. See Mayfield, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102 (2013). I. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Degenerative and traumatic arthritis, established by X-ray findings, are rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. See 38 C.F.R. § 4.71a, Diagnostic Codes (DC) 5003, 5010. If the limitation of motion of the involved joint(s) is noncompensable under the appropriate diagnostic code(s), a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion, to be combined, not added. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. A. Bilateral Retropatellar Pain Syndrome In a March 2006 rating decision, the RO granted entitlement to service connection for right and left knee retropatellar pain syndrome, and assigned an initial 10 percent rating for each knee, effective March 1, 2004, pursuant to 38 C.F.R. §4.71a, Diagnostic Codes 5299-5014 (2013). The Veteran's right and left knee disorders are currently evaluated under Diagnostic Codes 5299-5014, indicating an analogous rating to impairment resulting from osteomalacia. 38 C.F.R. §§ 4.27, 4.71a, Diagnostic Code 5014 (2013). Specifically, under Diagnostic Code 5014, osteomalacia will be rated based on limitation of motion of the affected part, as degenerative arthritis under 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5003, the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected, which in this case would be Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Under Diagnostic Code 5256, a 30 percent disability evaluation is assigned for ankylosis of the knee, favorable angle in full extension, or in slight flexion between 0 and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256 (2013). Under Diagnostic Code 5257, a 10 percent disability evaluation is assigned for mild recurrent subluxation or lateral instability. A 20 percent disability evaluation is warranted when such impairment is moderate. A 30 percent disability evaluation is assigned when such impairment is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2013). Under Diagnostic Code 5258, a 20 percent disability evaluation is assigned for dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2013). Under Diagnostic Code 5259, a 10 percent disability evaluation may be assigned for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2013). Under Diagnostic Code 5260, a 10 percent disability evaluation is warranted when flexion of the leg is limited to 45 degrees. A 20 percent disability evaluation is warranted when flexion is limited to 30 degrees. A 30 percent disability evaluation is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2013). Under Diagnostic Code 5261, a 10 percent disability evaluation is warranted when extension is limited to 10 degrees. A 20 percent disability evaluation is warranted when extension is limited to 15 degrees. A 30 percent disability evaluation is warranted when extension is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2013). Standard range of knee motion is from 0 degrees (extension) to 140 degrees (flexion). 38 C.F.R. § 4.71, Plate II (2013). VA's Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. VA's General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, the VA's General Counsel also held that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, and 4.59 must be considered. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent X-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. Painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. VA's General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examinations on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2013). The Court has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. The Board further recognizes that the Court recently determined that pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2013); see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 is not limited to arthritis). Finally, the Court has held that "within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise. To find otherwise would permit absurd results - compensation twice for the same condition ..."). See Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010); see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that separate ratings for limitations of both flexion and abduction of the shoulder were not permitted as this impairment arose from one disability). Background Post-service, the Veteran received VA outpatient clinic care in June and August 2004, and in September and October 2005 for bilateral knee degenerative joint disease; in June 2005 Feldene was prescribed. At a January 2006 VA examination, the Veteran reported a history of bilateral knee pain. Currently, he reported manifestations of pain throughout the day usually ameliorated by a hot bath as well as pain behind the retropatellar areas, morning stiffness on cold days, popping, cracking (crepitus) every day, and bilateral knee swelling. The Veteran denied bilateral knee buckling, locking, giving way, weakness, fatigue, or lack of endurance. He also denied using assistive devices, or any history of surgery, injections, after-service injury, fracture, dislocation, subluxation, or falling down secondary to the knees. He reported stable knee joints and denied any incapacitation. The examination showed normal anatomic landmarks without edema, effusion, weakness, redness, or heat. The examiner was able to uncover approximately 50 percent of the patella surface underneath, and digital pressure to this area elicited subjective complaints of pain. Active and passive ranges of motion were equal, and without arc pain motion in either knee. Flexion was to 135 degrees and extension was to 0 degrees, bilaterally. The range of motion was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. Strength was noted as 5/5. Lachman, drawer, pivot, McMurray, varus/valgus stress testing were negative. Grind test was positive for retropatellar pain syndrome. Radiographic studies of the Veteran's knees showed no osseous or articular abnormalities. The diagnosis was retropatellar pain syndrome of both knees without subluxation or instability of the knees. At a January 2007 VA examination, the Veteran reported bilateral knee pain and stated that his right knee was worse than the left knee. He reported stiffness exacerbated by cold weather. He took medications to control symptoms. The Veteran reported buckling, giving way, fatigue, and lack of endurance of the right knee. Left knee symptoms reported were stiffness, fatigue, and lack of endurance. The Veteran reported no incapacitation due to the knees. The examination showed his gait was normal. He denied fracture, surgical prosthesis, surgical intervention, prescription of brace, injections, prescriptive shoes for the bilateral knees. The Veteran's knees were tender to palpation. There was right knee range of motion to 0 degrees extension and to 130 degrees flexion. The left knee had 0 degrees extension and 125 degrees of flexion. The examiner reported no additional loss of motion due to functional impairment. There were negative results on Lachman, Drawer, pivot, McMurray, valgus/varus, and grind testing. The examiner indicated he believed that the knee patella was subluxing but could not prove it. He believed there was a high probability the patellae were normal during day-to-day activities. VA treatment records covering the period from January 2007 to March 2011 document complaints of knee pain. At a VA examination in November 2010, it was noted that the Veteran used medication and braces for the knees. The Veteran complained of giving way with pain. The examination showed no evidence of knee crepitation, grinding, or instability. There was bilateral subpatellar tenderness. Bilateral motion testing showed extension to 0 degrees and flexion to 125 degrees with pain. The examiner noted no additional loss of motion due to functional impairment. At his September 2012 Travel Board hearing, the Veteran testified that his doctor gave him a brace for his left knee because it gave out sometimes when he was walking upstairs. He also used a cane for the same reason. The Veteran stated that he was starting to have problems with his right knee because he was trying to compensate for his left knee. He testified that his knees gave out with walking, and sometimes stiffened up after walking. At a June 2013 VA examination, the Veteran reported daily bilateral knee pain, he described as throbbing, and worse when standing after having been seated for a prolonged period. The Veteran stated that he used a brace on a regular basis and a cane occasionally. The Veteran used Tramadol when needed for pain and knee braces. The examination of the right and left knees showed extension to 0 degrees and flexion to 120 degress with painful motion. The Veteran did not report that flare-ups impact the function of the knees. The examiner noted that the Veteran was able to perform repetitive use testing with three repetitions, and that after repetitive testing the Veteran's bilateral range of knee motion was still 0 to 120 degrees; it was noted that the Veteran did not have any additional limitation in range of motion of the knees or lower leg following repetitive use testing. The examiner did note that the Veteran had functional loss or functional impairment of the knee and lower leg in the form of less movement than normal and pain on movement of the bilateral knees. The Veteran had tenderness or pain to palpation. The examiner noted muscle strength of 5/5 in both knees and normal Lachman, Drawer, and valgus/varus testing of both knees. The examiner noted no evidence of recurrent patellar subluxation. There was no noted shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The examiner noted that the Veteran, on visual inspection of the lower extremities, had well developed muscles with marked muscular definition compatible with high physical/athletic activity. The Veteran had a normal gait and he was not using any assistive device during the examination. X-rays and imaging studies did not show degenerative or traumatic arthritis, nor was there evidence of patellar subluxation. There was also no osseous, articular or soft tissue abnormalities seen. The examiner also noted that the Veteran's knee disorders did not impact his ability to work. Analysis At no time during the course of the appeal has the evidence shown limitation of motion in either knee that meets the criteria for an evaluation higher than 10 percent under Diagnostic Codes 5260 or 5261. The Veteran has consistently demonstrated extension to 0 degrees and flexion to at least 120 degrees since service. The Board further finds that there is no basis for the assignment of a higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7. The evidence reflects that the currently assigned 10 percent rating properly compensates him for the extent of functional loss resulting from symptoms like painful motion, tenderness, and stiffness for each knee. In this regard, the Board notes that the Veteran has reported pain associated with his service-connected bilateral knee disability and has demonstrated tenderness of each knee when examined. The Court has held, however, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., (quoting 38 C.F.R. § 4.40). In theVeteran's case, each time the examiners performed repetitive motion testing on the Veteran, he was still able to extend each knee to 0 degrees, and flex each knee to 120 degrees. None of the examiners suggested that his motion was further functionally limited by pain. The Board consequently finds that the weight of the evidence is against a finding that pain or limitation of motion on repetitive use results in functional loss warranting the assignment of any increased evaluation. In fact, VA examination report findings dated in January 2007, November 2010, and June 2013 detailed objective evidence of pain on motion and no additional loss of motion noted on repetitive motion. Those findings have not shown limitation of the range of motion in his knees to warrant the assignment of higher ratings based on either flexion or extension or any of the other rating criteria relevant to the knees. Indeed, the November 2010 and June 2013 VA examiners clearly indicated that there was no functional impairment. Thus, the evidence of record does not reflect any findings of functional loss greater than that contemplated by the currently assigned 10 percent rating for each knee. The Board notes that the Veteran has reported buckling or giving way of his knees. He also reportedly uses braces. Notably, however, the Veteran's muscle strength was consistently 5/5 when examined, and there is no atrophy in either leg. Moreover, despite his use of a brace, he has not evidenced any gait disturbance. In short, the evidence does not demonstrate any knee weakness or incoordination that would suggest further functional loss. In sum, the Veteran's extension and flexion in both knees, even with consideration of any functional loss due to pain, are non compensable under either Diagnostic Code 5260 or 5261. Accordingly, a rating higher than 10 percent under either code is not warranted, and there is no basis to assign separate ratings for limitation of extension and flexion. To give the Veteran every consideration in connection with the matter on appeal, the Board must consider all potentially applicable diagnostic codes under 38 C.F.R. § 4.71a in rating the Veteran's bilateral knee disability. See, e.g., Butts v. Brown, 5 Vet. App. 532, 538 (1993) (the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case"), and Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (one diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology). The evidence of record is devoid of any findings of knee ankylosis, recurrent subluxation or lateral instability, dislocated or symptomatic semilunar cartilage, tibia or fibula impairment, or genu recurvatum for the assignment of a higher or separate rating under alternative rating criteria. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, and 5263. The Board is cognizant that the January 2007 VA examiner suspected that the knee patella was subluxing, but he notably indicated that he could not prove it, and in any event concluded that there was a high probability it was normal during day-to-day activities. There are also no other VA or private treatment records documenting instability and subsequent examiners noted the absence of any instability. Given the absence of any clinical finding of subluxation since service, the Board finds that the evidence does not establish that either knee has recurrent subluxation or lateral instability. Consequently, the assignment of an evaluation in excess of 10 percent for the Veteran's bilateral knee disability based upon any of these diagnostic codes, or a separate rating based on instability is not warranted. In sum, after a careful review of the evidence of record, the Board finds that the appeal for entitlement to initial ratings in excess of 10 percent for right and left knee retropatellar pain syndrome is not warranted. As the Veteran's symptoms have been consistent throughout the period involved in this claim, staged ratings are not warranted. Hart, 21 Vet. App. at 505. At no point during the relevant period did either knee disorder approximate the criteria for a higher rating. Since the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Left Carpal Tunnel Syndrome As already noted, the RO has assigned staged ratings for left carpal tunnel syndrome (10 percent prior to November 26, 2010, and 20 percent from that date), and both "stages" are for consideration. Where the minor extremity is affected by incomplete paralysis of the median nerve, a 40 percent rating is assigned for a severe level of disability, a 20 percent rating is assigned for a moderate level, and a 10 percent rating is assigned for a mild level. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Neuritis and neuralgia of the median nerve are rated using these criteria under Diagnostic Codes 8615 and 8715, respectively. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. When the involvement is bilateral, the ratings should be combined with application of the bilateral factor. Id. 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). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). In making these determinations, the Board takes notice of the evidence of record showing that the Veteran is right-handed, and thus the right arm will be considered the major (dominant) side, and the left will be considered the minor (non-dominant) side. 38 C.F.R. § 4.69 (2013). Background and Analysis The report of an April 2006 QTC examination showed slight decreased sensation over the median nerve distribution of the left hand and mild weakness of the pincer grasp between the thumb and index fingers. The Veteran reported having tingling or numbness in the left median nerve distribution which was increasing and was accompanied by some mild degree of weakness. The Veteran reported that he used a brace and Motrin. Testing showed reduced range of motion with dorsiflexion to 60 degrees and palmar flexion to 40 degrees with pain at both extremes. Radial and ulnar deviations were normal, without pain. Joint function was not additionally impaired after repetitive motion. Neurological testing showed findings of neuritis with slight weakness in the left pincer grasp between the thumb and index finger. Motor power was 5- and there was a slight decrease in light touch and pin prick in the left median nerve distribution. Reflex response was normal. Tinel's sign was absent, but Phalen's test was positive on the left. At a January 2007 VA examination, the Veteran reported experiencing some numbness and tingling of the left hand. He wore a wrist brace and exhibited mild weakness. The examination found normal strength with some slightly decreased grip strength. Sensory testing was intact. The Veteran had a positive Tinel's sign. VA outpatient records show that an Electromyograph (EMG) done in December 2008 revealed muscle strength in the left arm to be 5/5, with no atrophy. The study found left median sensory neuropathy, and the Veteran was advised to wear a wrist splint and continue medication for pain relief. After reviewing the evidence of record, the Board finds that the criteria for a rating in excess of 10 percent for left carpal tunnel syndrome for the period prior to November 26, 2010 are not met. The medical evidence clearly shows that the Veteran's neurological symptoms associated with the carpal tunnel syndrome are no more than mild in nature. The Veteran requires the use of a wrist brace and had mild weakness in the wrist. The April 2006 examiner found mild weakness in grasping strength with slightly decreased sensation but normal reflexes. The VA examination in January 2007 found normal strength with some slightly decreased grip strength, but with intact sensation. A VA EMG performed in December 2008 found evidence of left median sensory neuropathy, but noted the presence of normal strength and the absence of atrophy. The level of sensory disturbance has not been objectively shown to be more than mild in degree. The Veteran is competent to report on his left wrist symptoms. The nature and degree of severity of his carpal tunnel syndrome, however, is a medically complex matter, and thus the medical evidence is more probative in assessing whether the Veteran's overall disability more closely approximates a higher rating. Given the evidence showing substantially full to full left wrist strength, with no more than mild weakness in grasp, the Board finds that a rating in excess of 10 percent for carpal tunnel syndrome of the left hand for the period prior to November 26, 2010 is not warranted. At a November 2010 VA examination, the Veteran complained of increased numbness and decreased dexterity. He wore a night splint. Sensory examination was decreased to light touch. Motor examination showed 4/5 strength with normal muscle tone and no atrophy. The function of the joint was not affected. The Veteran reported no relief of pain, and indicated that it was exacerbated by activity. Manual muscle testing showed 3+/5 grasp, and there was some thenar atrophy with palmar wasting. An EMG study noted slight worsening of the carpal tunnel syndrome. Testing showed neuralgia with moderate effects on tasks involving fine manual dexterity. At his September 2012 Travel Board hearing, the Veteran testified that he was starting to drop things more often, feeling the pain more, and having trouble picking things up regardless of weight. At the June 2013 VA examination, the Veteran reported the gradual onset of carpal tunnel syndrome symptoms. The examiner noted that the Veteran had a peripheral nerve condition of the left upper extremity which was moderate in nature. It was noted that the Veteran had problems with lifting more than 20 pounds due to weakness of the left hand and also difficulty with fine motor skills of the left hand including probing, twisting, writing, and typing. EMG studies in conjunction with the examination found evidence of a focal left sensory median neuropathy at or about the wrist without evidence of axonal loss - consistent with carpal tunnel syndrome. Atrophy was noted at the left hypothenar area. Decreased pinprick over the dorsal hand and finger strength of 3/5 was noted on both hands. Neurological testing also showed Tinel's sign and Phalen's sign were positive bilaterally. For the period beginning on November 26, 2010, the Board finds that the criteria for a rating in excess of 20 percent for left carpal tunnel syndrome are not met. The evidence does not show that the symptoms of the Veteran's left carpal tunnel syndrome, which involve his non-dominant extremity, were more than moderately disabling on or after November 26, 2010. His symptoms clearly worsened when compared to examinations prior to November 2010, but notably, he retains substantial strength in the left wrist of 4/5, and grip strength of 3+/5. November 2010 VA examination testing showed neuralgia with moderate effects as to tasks involving fine manual dexterity. The June 2013 VA examiner noted that the Veteran had a peripheral nerve condition of the left upper extremity which was moderate in nature. Both examiners described the nerve disorder as moderate in nature, and the Board finds their description is consistent with the claimed findings. Therefore, the Board finds that an evaluation in excess of 20 percent on or after November 26, 2010, is not warranted. As previously discussed, while the Veteran is competent to report on symptoms, the nature and degree of severity of his disorder involves a medically complex matter. The medical evidence is more probative in assessing whether the Veteran's overall disability more closely approximates a higher rating. The June 2013 VA examiner specifically noted in the examination findings incomplete paralysis of the median nerve which was moderate in nature. Absent probative evidence of more than moderate impairment, a rating in excess of 20 percent for left carpal tunnel syndrome for the period beginning on November 26, 2010 is not warranted. The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine is inapplicable in the instant case because the preponderance of the evidence is against the Veteran's claim for an increased evaluation prior to and after November 26, 2010. See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Accordingly, higher ratings for the Veteran's left carpal tunnel syndrome are denied. Extra-Schedular Consideration Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). There is no allegation or evidence of exceptional factors in this appeal with regard to the Veteran's service-connected bilateral knee disability. The symptoms of these disabilities are knee pain, giving way, stiffness, and buckling. These symptoms are contemplated by the applicable diagnostic criteria, particularly as VA is required to consider those specific symptoms and like symptoms through application of 38 C.F.R. §§ 4.40 and 4.45. Thus, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1). Regarding the Veteran's service-connected left carpal tunnel syndrome, turning to the first step of the extra-schedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's left carpal tunnel syndrome is specifically contemplated by the schedular rating criteria (Diagnostic Code 8615, 38 C.F.R. § 4.124a), and no referral for extra-schedular consideration is required. The schedular rating criteria at Diagnostic Code 8615 specifically provide for disability ratings based on a combination of history, symptoms, and clinical findings. For the rating period prior to November 26, 2010, the Veteran's left carpal tunnel has been manifested by symptomatology approximating mild incomplete paralysis of the median nerve. For the rating period from November 26, 2010, the Veteran's left carpal tunnel has been manifested by symptomatology approximating moderate incomplete paralysis of the median nerve. The rating criteria provide for a range of symptoms by specifically designating a level of severity, rather than discrete symptoms, to establish a particular rating. The schedular rating criteria specifically contemplate ratings based on incomplete paralysis of the median nerve on the minor side. In this case, comparing the Veteran's disability level and carpal tunnel symptomatology to the Rating Schedule, the degree of disability throughout the entire period under consideration is contemplated by the Rating Schedule and the assigned ratings are, therefore, adequate. As the schedular evaluations contemplate the Veteran's level of disability and symptomatology for the bilateral knee and left carpal tunnel disabilities, the Board need not determine whether there is an exceptional disability picture that exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1). In the absence of evidence that the schedular rating criteria are inadequate to rate the Veteran's disabilities, the Board is not required to remand the issues of a higher initial rating for bilateral knee and higher staged ratings for left carpal tunnel syndrome to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See also Bagwell at 337; Shipwash at 227. II. Service Connection for Nasal Scar Residuals, Status Post Rhinoplasty with Septoplasty and Cartilage Graft Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuirt has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Background and Analysis Service treatment records (STR) show that the Veteran underwent elective surgery to correct hypertrophic nasal tip, mildly deviated septum to the left and hypoplastic chin in August 1988. A mild deviation to the left, with no history of airway obstruction, was noted. At a June 2011 VA examination, the Veteran reported a long history of allergic rhinitis. He indicated that as part of his nasal examination work up for nasal allergy, he was diagnosed with a nasal septum deviation in 1996 (in service) and had surgery that year to correct this problem. The Veteran had a rhinoplasty with septoplasty and cartilage graft. He reported that secondary to this surgery he developed problems with deformity at the left side of the nose where donor cartilage was removed for the graft and with a recurrent "lump" next to the same scar. On examination, the examiner noted a broad nose with widened nasal tip dorsum with mild indurated area (about 0.5 square centimeters) with subcutaneous induration on the left side next to the scar area on the donor site, with mild elevation of the area but no evident active cyst noted. No active skin lesions on the nasal skin area were present. The diagnosis was deviated nasal septum, status post rhinoplasty with septoplasty and cartilage graft with residual scar. At his September 2012 Travel Board hearing, the Veteran testified that he had residual scarring as a result of a cartilage graft performed in service to correct his deviated septum. At a June 2013 VA examination, the examiner noted that the Veteran had a long nose with a bulbous tip that looked symmetric, with healed nasal scars over the left nasal and columella. No skin lesions or tenderness to palpation were noted. Hypertrophy on the nasal turbinates was noted without significant obstruction. No nasal polyps were noted. The diagnosis was nasal scars, status post rhinopolasty with septoplasty and cartilage graft, with residuals. The above evidence clearly shows that the Veteran has nasal scars over the left nasal and columella, which constitutes a current disability. See 38 C.F.R. § 4.118. The evidence also shows that the scars reslted from a rhinoplasty with septoplasty and cartilage graft in service. Regardless of the elective nature of the service surgeries, the resulting scars clearly were first present in service in the line of duty. Accordingly, the Board finds that service connection for the nasal scar residuals, status post rhinoplasty with septoplasty and cartilage graft is warranted on the evidence of record, and the claim is granted. 38 C.F.R. §§ 3.102, 3.303. In reaching this conclusion, the benefit of the doubt doctrine has been appropriately applied. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to an evaluation in excess of 10 percent for retropatellar pain syndrome of the right knee is denied. Entitlement to an evaluation in excess of 10 percent for retropatellar pain syndrome of the left knee is denied. Entitlement to an evaluation in excess of 10 percent prior to November 26, 2010, for left carpal tunnel syndrome is denied. Entitlement to an evaluation in excess of 20 percent from November 26, 2010, for left carpal tunnel syndrome is denied. Entitlement to service connection for nasal scar residuals, status post rhinoplasty with septoplasty and cartilage graft is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND In an April 2013 Board decision, the Board remanded the issue of entitlement to service connection for status post rhinoplasty with septoplasty and cartilage graft for a medical opinion to ascertain the nature and etiology of any residuals of the Veteran's service rhinoplasty with septoplasty and cartilage graft. The examiner was specifically requested to identify each currently present residual of the rhinoplasty and septoplasty with cartilage graft performed in service. The examiner was asked to specifically include any balance or inner ear problems associated with the cartilage graft. However, the examiner failed to give an opinion concerning any balance or inner ear problems associated with the in-service procedure. As such, the board finds that a second remand is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the Veteran's June 2013 VA examination for left carpal tunnel syndrome, the examiner noted that the Veteran's peripheral nerve condition impacted his ability to work; however, no further details concerning unemployability were noted. As such, entitlement to a TDIU must be addressed in connection with this appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to identify all sources of treatment, VA and private, for the remaining disability at issue. With any necessary authorizations from the Veteran, obtain and associate with the claims file all outstanding records of treatment identified by the Veteran. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. If the records are unavailable, notify the Veteran in accordance with 38 C.F.R. § 3.159(e). 2. After any additional records are associated with the claims file, schedule the Veteran for an otolaryngological examination to assess the nature and etiology of any residuals of his inservice rhinoplasty with septoplasty and cartilage graft, other than nasal scars. The claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the examination. All findings should be reported in detail and any indicated tests or studies should be completed (to specifically include any balance or inner ear problems associated with the cartilage graft). The examiner is specifically requested to identify each currently present residual of the rhinoplasty and septoplasty with cartilage graft performed in service to include, if present, nasal polyps or nasal obstruction. The examiner should explain the rationale for all opinions provided. 3. Schedule the Veteran for an examination to determine the impact of his service connected disabilities on his employability. The examiner is to provide an opinion as to whether the Veteran's combined service-connected disabilities, either alone or in the aggregate, render him unable to secure and follow a substantially gainful occupation. The examiner should note that this opinion is without regard to the Veteran's age or the impact of any nonservice-connected disabilities on his ability to secure or follow a substantially gainful occupation. The examiner should set forth a complete rationale for all findings and conclusions in the report provided. 4. Thereafter, the RO/AMC should readjudicate the issue remaining on appeal. If the determination remains unfavorable to the appellant, he and his representative should be provided with a supplemental statement of the case that addresses all relevant actions taken on the claim for benefits, to include a summary of the evidence and applicable law and regulations considered. The appellant and his representative should be given an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs