Citation Nr: 1338317 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 07-20 868A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and Parkinson's disease. 2. Entitlement to a rating in excess of 30 percent for peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis, prior to December 21, 2007. 3. Entitlement to a rating in excess of 40 percent for peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis and Parkinson's tremors, beginning December 21, 2007. 4. Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity with carpal tunnel syndrome and deQuervain's tenosynovitis of the left hand and wrist, prior to December 21, 2007. 5. Entitlement to a rating in excess of 30 percent for peripheral neuropathy of the left upper extremity with carpal tunnel syndrome, deQuervain's tenosynovitis of the left hand and wrist, and Parkinson's tremors, beginning December 21, 2007. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from July 1966 to July 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which, in pertinent part, increased the ratings assigned peripheral neuropathy of the right and left upper extremities and found that new and material evidence had not been submitted to reopen a claim for entitlement to service connection for hypertension. Jurisdiction over the claims file is currently held by the RO in Detroit, Michigan. The Veteran testified at a videoconference hearing before the undersigned Acting Veterans Law Judge (VLJ) in July 2012. A transcript of the hearing is associated with the claims file. In September 2012, the Board found new and material had been submitted to reopen the hypertension claim and remanded the case for further action by the originating agency. The case has now returned to the Board for further appellate action. In a December 2010 rating decision, service connection was awarded for Parkinson's disease as presumptively associated with herbicide exposure during Vietnam. Parkinson's disease will be assigned a minimum rating of 30 percent for ascertainable residuals, under diagnostic code 8004, or rated separately based on specific residuals. See 38 C.F.R. §§ 4.120 , 4.124a, Code 8004 and Note to Codes 8000-8025 (2013). In this case, the RO assigned separate evaluations for neuropsychiatric impairment and for neurological symptoms of the right and left lower extremities and the right and left upper extremities, effective December 21, 2007. As pertinent to this appeal, the Parkinson's disease symptoms of the right and left upper extremities were rated together with the Veteran's previously service-connected upper extremity neurological conditions, and the rating for each upper extremity disability was increased by 10 percent. Thus, insofar as the Veteran's Parkinson's disease affects the upper extremities, effective December 21, 2007, it must be considered as part of the current appeal, as set forth on the title page. FINDINGS OF FACT 1. Hypertension was not manifested within one year from the Veteran's discharge from service, is not the result of a disease or injury in service, and is not caused or aggravated by a service-connected disability. 2. During the period prior to December 21, 2007, the Veteran's peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis most nearly approximated incomplete paralysis of the ulnar nerve that was no more than moderate. 3. During the period beginning December 21, 2007, the Veteran's peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis and Parkinson's tremors most nearly approximates incomplete paralysis of the ulnar nerve that is no more than severe. 4. During the period prior to December 21, 2007, the Veteran's peripheral neuropathy of the left upper extremity with carpal tunnel syndrome and deQuervain's tenosynovitis of the left hand and wrist most nearly approximated incomplete paralysis of the ulnar nerve that was no more than moderate. 5. During the period beginning December 21, 2007, the Veteran's peripheral neuropathy of the left upper extremity with carpal tunnel syndrome, deQuervain's tenosynovitis of the left hand and wrist, and Parkinson's tremors most nearly approximates paralysis of the ulnar nerve that is no more than severe. 6. During the period beginning November 8, 2012, the Veteran's deQuervain's tenosynovitis of the left hand and wrist manifests limitation of dorsiflexion of the wrist to 60 degrees. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by active service, nor may it be presumed to have been incurred therein, and it is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. During the period prior to December 21, 2007, the criteria for a rating in excess of 30 percent for peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis have not ben met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, 4.124a, Diagnostic Codes 5003, 5024, 8516. 3. During the period beginning December 21, 2007, the criteria for a rating in excess of 40 percent for peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis and Parkinson's tremors have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, 4.124a, Diagnostic Codes 5003, 5024, 8516. 4. During the period prior to December 21, 2007, the criteria for a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity with carpal tunnel syndrome and deQuervain's tenosynovitis of the left hand and wrist have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, 4.124a, Diagnostic Codes 5003, 5024, 8516. 5. During the period beginning December 21, 2007, the criteria for a rating in excess of 30 percent for peripheral neuropathy of the left upper extremity with carpal tunnel syndrome, deQuervain's tenosynovitis of the left hand and wrist, and Parkinson's tremors have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, 4.124a, Diagnostic Codes 5003, 5024, 8516. 6. During the period beginning November 8, 2012, the criteria for a separate 10 percent rating for limitation of motion from deQuervain's tenosynovitis of the left hand and wrist are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, 4.124a, Diagnostic Codes 5003, 5024, 5215, 8516. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Claim The Veteran contends that service connection is warranted for hypertension as it was caused or aggravated by his service-connected diabetes mellitus and Parkinson's disease. As a preliminary matter, the Board notes that the Veteran also originally claimed that service connection was warranted for hypertension as directly related to active duty service and his exposure to herbicides in the Republic of Vietnam. However, in a December 2008 statement, the Veteran withdrew his contention that service connection was warranted for hypertension as due to herbicide exposure. The Board has a duty to consider all theories of entitlement raised either by the claimant or by the evidence of record as part of the non-adversarial administrative adjudication process. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009). In this case, the Veteran specifically withdrew his argument pertaining to a link between hypertension as due to herbicide exposure. Additionally, hypertension is not a disease that is presumed associated with herbicide agents under 38 C.F.R. §§ 3.307 and 3.309. There is also no evidence, lay or medical, in the record reasonably raising herbicide exposure as a theory of entitlement. Therefore, the Board will not address this theory of entitlement in the discussion below. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service--the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)(holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, such as hypertension, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection is also provided for a disability, which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310.; Allen v. Brown, 7 Vet. App. 439 (1995). The Board will first address whether service connection is warranted for hypertension on a secondary basis as due to service-connected diabetes mellitus or Parkinson's disease. The record clearly establishes the presence of a current disability-the Veteran was diagnosed with hypertension during VA examinations in July 2003 and November 2012. He has also received treatment for hypertension at the Battle Creek and Ann Arbor VA Medical Centers (VAMCs) throughout the claims period. Therefore, the first element of service connection-a current disability-is present. The Board finds that the competent medical evidence of record does not demonstrate a relationship between the Veteran's hypertension and service-connected diabetes mellitus and/or Parkinson's disease. The Veteran has not submitted any medical evidence in support of his claim and has not reported that any of his private physicians have identified a nexus between his hypertension and service-connected conditions. In July 2012, he submitted a copy of a scientific article studying the incidence and severity of hypertension in patients with severe primary autonomic failure, but the results of the study actually weigh against the claim for secondary service connection. The study found that blood pressure levels in patients with Parkinson's disease were no different from a control group. In addition, a case-control study found that Parkinson's patients had lower blood pressures and a lower incidence of hypertension when compared to age-matched controls. These findings weigh against a conclusion that the Veteran's Parkinson's disease aggravated his hypertension and do not support the claim. In addition, the record contains a November 2012 VA medical opinion weighing against the claim. After examining the Veteran and reviewing the pertinent evidence in the claims file, the November 2012 VA examiner concluded that service-connected diabetes mellitus and Parkinson's disease had not caused or aggravated the Veteran's hypertension. The examiner noted that diabetes and hypertension were diagnosed at approximately the same time in 1998, but the Veteran had no renal insufficiency or dysfunction. Hypertension is considered a consequence of diabetes only when there is renal involvement. Furthermore, the Veteran was not diagnosed with Parkinson's until 2006-almost a decade after the finding of hypertension. Hypertension is also not a known complication of Parkinson's disease or its associated medication. With respect to the question of aggravation, the VA examiner noted that the Veteran's blood pressure levels have remained stable and his Parkinson's medication is also used to regulate blood pressure. In short, there was no indication that the Veteran's hypertension had been aggravated by service-connected diabetes or Parkinson's disease. The November 2012 medical opinion was rendered following a physical examination and review of the Veteran's claims file. Although the examiner noted that service treatment records were not included in the claims file, these records are not relevant to a service connection claim on a secondary basis. Furthermore, the Veteran specifically reported to the VA examiner that he did not undergo any treatment for hypertension during active duty service. The Board therefore finds that the lack of service treatment records in the claims file at the time of the VA examination does not lessen the probative value of the November 2012 VA examiner's medical opinion. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). In fact, as the November 2012 medical opinion was well-supported and based on an accurate presentation of the facts in this case, the opinion is entitled to substantial probative value. The Board has considered the statements of the Veteran linking his hypertension to service-connected diabetes and Parkinson's disease, to include his specific contentions regarding a "diabetic look back" basis for service connection. Essentially, the Veteran contends that although hypertension and diabetes were officially diagnosed at approximately the same time, he was treated for borderline diabetes several years prior to a formal diagnosis and developed hypertension as his diabetes progressed. In a December 2002 letter, the Veteran's private physician noted that Veteran first demonstrated glucose intolerance in 1994 or 1995, several years before diabetes mellitus was actually diagnosed. However, the private physician did not discuss whether any relationship exists between the Veteran's diabetes and hypertension. Additionally, as noted above, there is no competent medical evidence of such a relationship and the November 2012 VA examiner specifically found that the Veteran's hypertension did not include any renal involvement, a requirement for diabetes-related hypertension. In short, while the Veteran is competent to report observable symptoms of his claimed disabilities, his opinion as to the cause of his hypertension simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the etiology of hypertension falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4 (lay persons not competent to diagnose cancer). As such, the Veteran's own assertions as to etiology have no probative value. His lay statements are clearly outweighed by the competent medical evidence of record, including the medical opinion of the November 2012 VA examiner. The Board must therefore conclude that service connection for hypertension on a secondary basis is not warranted. Regarding whether service connection is warranted on a direct basis, service treatment records are completely negative for any evidence of high blood pressure or hypertension. The Veteran's VA and private physicians have dated the onset of hypertension to 1998, approximately 30 years after the Veteran's separation from active duty service. Moreover, there is no competent evidence of a link between the Veteran's hypertension and active duty service. The Veteran has not reported a continuity of symptomatology, nor has he specifically contended that hypertension was incurred during active duty. The November 2012 VA examiner also provided a well-reasoned and supported medical opinion weighing against service connection for hypertension as directly due to military service. In sum, the post-service evidence of record shows that the first evidence of the Veteran's claimed disability was many years after his separation from active duty. There is no evidence of hypertension within a year after service to allow for a grant of service connection on a presumptive basis as a chronic disease. 38 C.F.R. §§ 3.307, 3.309 (2013). In addition, the competent medical evidence does not establish that the Veteran's hypertension was incurred secondary to service-connected diabetes mellitus, Parkinson's disease, or active service. The Board therefore concludes that the evidence is against a nexus between the Veteran's hypertension and a service-connected disability or active duty service. The Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C.A. § 5107(b) (West 2002). Increased Rating Claims Service connection for peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis of the right wrist was granted in an October 2003 rating decision with an initial 10 percent evaluation assigned effective December 20, 2001. Service connection for carpal tunnel syndrome of the left upper extremity with deQuervain's tenosynovitis of the left wrist and hand was also granted in the October 2003 rating decision with an initial 10 percent evaluation assigned effective December 20, 2001. The September 2006 rating decision on appeal granted increased ratings for the disabilities; peripheral neuropathy of the right upper extremity was increased to 30 percent disabling effective March 13, 2006, while peripheral neuropathy of the left upper extremity was increased to 20 percent disabling, also effective March 13, 2006. The assigned disability evaluations for the Veteran's peripheral neuropathy of the upper extremities was again increased in a December 2010 rating decision. The right upper extremity was evaluated as 40 percent disabling from December 21, 2007, while the left upper extremity was evaluated as 30 percent disabling, also from December 21, 2007. The disabilities were also recharacterized to include consideration of the Veteran's service-connected Parkinson's tremors. Thus, the Veteran's service-connected peripheral neuropathy of the right upper extremity was rated as 30 percent disabling prior to December 21, 2007 and 40 percent disabling thereafter. The service-connected peripheral neuropathy of the left upper extremity was rated as 20 percent disabling prior to December 21, 2007 and 30 percent thereafter. The Veteran contends that increased evaluations are warranted throughout the claims period as he experiences weakness and decreased strength and sensation in both upper extremities. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, 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 relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's peripheral neuropathy of the upper extremities is currently rated under Diagnostic Code 5024, pertaining to tenosynovitis. This diagnostic code provides for rating the disease based on limitation of motion of the affected part as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5024 (2013). The Veteran's neurological symptoms of peripheral neuropathy are rated by analogy to Diagnostic Code 8516 and paralysis of the ulnar nerve. Under this diagnostic code, mild incomplete paralysis is rated 10 percent disabling on the major side and 10 percent on the minor side; moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side; and severe incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side. Complete paralysis of the ulnar nerve, the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers, cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened, is rated 60 percent disabling on the major side and 50 percent on the minor side. 38 C.F.R. § 4.124a, Diagnostic Code 8516. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. Turning first to the period prior to December 21, 2007, the Board finds that increased evaluations are not warranted for the Veteran's bilateral upper extremity disabilities. The Veteran is right hand dominant, and his right (major) upper extremity is currently rated as 30 percent disabling prior to December 21, 2007. The left (minor) upper extremity is rated as 20 percent disabling during this period. Under Diagnostic Code 8516, these ratings are consistent with moderate incomplete paralysis in the ulnar nerves. 38 C.F.R. § 4.124a, Diagnostic Code 8516. After review of the evidence, the Board finds that the Veteran's service-connected peripheral neuropathy of the upper extremities most nearly approximates the criteria associated with the currently assigned ratings during the period prior to December 21, 2007. During the period prior to December 21, 2007, the Veteran manifested symptoms of numbness and tingling in the bilateral hands and fingers with associated weakness and some functional loss. Upon VA examination in April 2006, he complained of constant numbness and tingling in the hands with no pain. He complained of dropping objects and burning his hands. Physical examination showed overall good muscle strength of upper extremities with only a slightly reduced (4/5) ability to grasp with the right hand. The Veteran's deep tendon reflexes were symmetrical and full and while there was some decrease in sensation to temperature, the Veteran was sensitive to light touch and vibratory sense was intact. The Veteran had full range of motion of the hands and fingers and was able to make a very tight fist with both hands. Monofilament testing was absent over the dorsum of both hands and the bilateral fingers. The examiner also observed a severe tremor of the right upper extremity and an absent to mild tremor on the left. The examiner concluded that the Veteran's neuropathy had progressed since the last VA examination in July 2003, but the Veteran was still able to perform the activities of daily living. Similar findings were made during neurological examinations conducted at the Ann Arbor VAMC. In May 2006, the Veteran had a mild deficit to temperature sense in the bilateral hands and mild vibratory loss on the right. Strength of the upper extremities remained full with intact reflexes in December 2006, and in January 2007, the Veteran manifested an essential tremor that interfered with his handwriting. The tremor improved with medication and the Veteran reported that his left hand was not bothersome. Strength in both upper extremities was again full and reflexes were somewhat reduced (2/4). Sensation to light touch was intact bilaterally. Six months later, in July 2007, the Veteran made similar complaints reporting that he had trouble with writing, grasping, and controlling his hands. The record therefore establishes that the Veteran manifested symptoms of neurological impairment including weakness, a loss of control, and numbness over the hands and fingers. The Veteran manifested some decrease to sensation in temperature, but light touch and vibratory sense remained mostly intact. The bilateral upper extremity tremor was improved with medication and strength in the upper extremities remained full upon VA examination and with further testing at the Ann Arbor VAMC. The Veteran complained of functional impairments involving his handwriting and problems with grasping and holding objects, but was able to perform all activities of daily living. The Board finds that the Veteran's complaints and symptoms during this period do not more nearly approximate the next higher rating for the right and left upper extremity. The Board has also considered whether the Veteran's disability warrants a separate compensable rating for limitation of motion associated with the service-connected peripheral neuropathy with deQuervain's tenosynovitis. As noted above, the Veteran's disability is rated under Diagnostic Codes 5003 and 5024 pertaining to tenosynovitis and arthritis in addition to Diagnostic Code 8516 for impairment of the ulnar nerve. Diagnostic Codes 5003 and 5024 consider ratings based on limitation of motion, not neurological impairment as contemplated by Diagnostic Code 8516. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). While the criteria associated with complete paralysis of the ulnar nerve under Diagnostic Code 8516 contemplate some limitation of motion of the upper extremity, the criteria for rating incomplete paralysis do not specify limitation of motion as part of the disability picture for neurological impairment. The Board will resolve all doubt in the Veteran's favor and conclude that a separate rating is possible for limitation of motion of the upper extremities to the extent that the Veteran is compensated for incomplete paralysis of the ulnar nerve. Thus, if the Veteran manifests limitation of motion of the right and/or left upper extremities, a separate rating may be warranted as this symptom of the service-connected disability is separate and distinct from the neurological impairment detailed above. During the period prior to December 21, 2007, the Veteran did not manifest any limitation of motion of the right or left upper extremity. Range of motion of both upper extremities was full at the April 2006 VA examination and none of the Veteran's physicians at the VAMC identified any loss of motion of the right or left arms, hands, or fingers. Diagnostic Code 5003 provides for a 10 percent evaluation for joints with noncompensable limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). However, as the Veteran did not manifest any limitation of motion during this period, a 10 percent evaluation is not warranted under Diagnostic Code 5003. For the period beginning December 21, 2007, the Veteran's peripheral neuropathy of the right (major) upper extremity is rated as 40 percent disabling while his peripheral neuropathy of the left (minor) upper extremity is rated as 30 percent disabling. Both ratings are consistent with severe incomplete paralysis of the ulnar nerves under Diagnostic Code 8516. The Board finds that increased ratings are not warranted for either upper extremity during this period as the evidence does not establish the disability most nearly approximates complete paralysis of the ulnar nerves. During the period beginning December 21, 2007, there is no evidence of complete paralysis of the ulnar nerve. The Veteran has manifested increasing difficulties with fine motor function, grip strength, and weakness, but has clearly not experienced symptoms that most nearly approximate complete paralysis. There is no evidence of a "griffin claw" deformity and there is no atrophy of the right or left upper extremities. Upon VA examination in November 2012, the VA examiner specifically found that the Veteran demonstrated only mild incomplete paralysis of the left and right ulnar nerves. Severe numbness and a severe Parkinson's tremor were noted by the March 2010 and November 2012 VA examiners, but severe incomplete paralysis is contemplated by the Veteran's current 40 and 30 percent ratings for each upper extremity. Neurological examinations at the Ann Arbor VAMC conducted throughout the claims period have also demonstrated symptoms that most nearly approximate the current evaluation for severe incomplete paralysis of the ulnar nerves. The Veteran has manifested increased loss of sensation, but motor and vibratory senses are intact. There is no evidence that the Veteran is unable to spread his fingers or that range of motion has been so limited in the thumb and wrist as to most nearly approximate complete paralysis. In fact, the November 2012 VA examiner noted that the Veteran's complaints associated with left carpal tunnel syndrome resolved following a left carpal tunnel release in June 2009. Range of motion of the wrist was full except for slight limitation of left wrist dorsiflexion to 60 degrees with consideration of the Veteran's complaints of pain. There was no additional loss of motion with repetitive testing. It is therefore clear that the Veteran's service-connected disabilities of the upper extremities have not most nearly approximated complete paralysis of the ulnar nerves at any time during the period prior to December 21, 2007. The Board has again considered whether a separate rating is warranted for limitation of motion of the upper extremities in accordance with Diagnostic Codes 5024 and 5003 for rating tenosynovitis and arthritis. Upon VA examination in November 2012, the Veteran had a slight decrease in left wrist dorsiflexion to 60 degrees. There was no additional loss of motion following repetitive testing. A compensable (10 percent) rating for limitation of motion of the wrist is warranted when dorsiflexion is less than 15 degrees or palmar flexion is limited in line with the forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The Veteran's limitation of motion of the left wrist clearly does not most nearly approximate these criteria; however, a 10 percent separate ratings is warranted under Diagnostic Code 5003 for painful noncompensable limitation of motion of the left wrist. Thus, the Board finds that a separate 10 percent rating is warranted for the Veteran's noncompensable limitation of motion of the left wrist for the period beginning November 8, 2012, the date the left wrist first demonstrated loss of motion. A separate rating is not warranted for the right upper extremity as there is no competent evidence of loss of motion. In conclusion, the Veteran's peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis and Parkinson's tremors warrants a 30 percent rating for the period prior to December 21, 2007 and a 40 percent rating thereafter. Peripheral neuropathy of the left upper extremity with carpal tunnel syndrome, deQuervain's tenosynovitis, and Parkinson's tremors warrants a 20 percent for the period prior to December 21, 2007 with a 30 percent rating thereafter. A separate 10 percent rating is also warranted for limitation of motion associated with the Veteran's left deQuervain's tenosynovitis for the period beginning November 8, 2012. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court of Appeals for Veterans Claims (Court) has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disabilities. The Veteran's service-connected peripheral neuropathy with carpal tunnel syndrome, deQuervain's tenosynovitis, and Parkinson's tremors is manifested by symptoms such as numbness, weakness, loss of strength and fine motor skills, and in the case of the left wrist, a slight loss of motion. These manifestations are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disabilities and referral for consideration of extraschedular rating is not warranted. 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, 5126 (West 2002)) defined VA's duties to notify and assist a veteran in the substantiation of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In this case, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) regarding the claim for service connection on a direct and secondary basis and the claims for increased ratings was furnished to the Veteran in a March 2006 letter. The Veteran also received notice regarding the disability-rating and effective-date elements of the claim in the March 2006 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, records of VA treatment, and a statement from his private physician. The Veteran has not identified any additional records that could be used to support his claims. Additionally, he was provided proper VA examinations and medical opinions in November 2012. The Board also finds that VA has complied with the September 2012 remand orders of the Board. In response to the Board's remand, the Veteran's service treatment records were obtained and associated with the claims file. Records of treatment from the Ann Arbor VAMC for the period beginning January 2010 were also added to the virtual claims file. The Veteran was provided VA examinations to determine the etiology of his hypertension and current severity of his peripheral neuropathy in November 2012. The case was then readjudicated in a May 2013 supplemental statement of the case (SSOC). Therefore, VA has complied with the remand orders of the Board. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and Parkinson's disease, is denied. Entitlement to a rating in excess of 30 percent for peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis, prior to December 21, 2007 is denied. Entitlement to a rating in excess of 40 percent for peripheral neuropathy of the right upper extremity with deQuervain's tenosynovitis and Parkinson's tremors, beginning December 21, 2007 is denied. Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity with carpal tunnel syndrome and deQuervain's tenosynovitis of the left hand and wrist, prior to December 21, 2007 is denied. Entitlement to a rating in excess of 30 percent for peripheral neuropathy of the left upper extremity with carpal tunnel syndrome, deQuervain's tenosynovitis of the left hand and wrist, and Parkinson's tremors, beginning December 21, 2007 is denied. Entitlement to a separate 10 percent rating for limitation of motion from deQuervain's tenosynovitis of the left hand and wrist for the period beginning November 8, 2012 is granted. ____________________________________________ M. C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs