Citation Nr: 1343005 Decision Date: 12/27/13 Archive Date: 01/07/14 DOCKET NO. 10-04 699 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial compensable disability rating prior to March 16, 2010 and a rating in excess of 10 percent from March 16, 2010 for service-connected right shoulder and bicep tendonitis. 2. Entitlement to an initial compensable disability rating for service-connected left ankle spurs. 3. Entitlement to service connection for right carpal tunnel syndrome. 4. Entitlement to service connection for left carpal tunnel syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty from May 1988 to October 2008. This appeal arises before the Board of Veterans' Appeals (Board) from a January 2009 rating decision rendered by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina as part of the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. In order to facilitate the quick processing of claims under the BDD program, the Virtual VA paperless processing system is utilized. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the appeal was processed using the Virtual VA paperless claims processing system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. In the January 2009 rating decision, the RO in part, granted service connection for right shoulder and bicep tendonitis; and left ankle spurs at noncompensable evaluations, effective November 1, 2008; and denied service connection for left and right carpal tunnel syndrome. In a January 2012 rating decision, the RO, in part, increased the evaluation for right shoulder and bicep tendonitis to a 10 percent rating, effective March 16, 2010. The Board notes that since the increase to 10 percent did not constitute a full grant of the benefits sought, the increased rating issue for the period since March 16, 2010 remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). FINDINGS OF FACT 1. For the entire appeal period, the Veteran's service-connected right shoulder and bicep tendonitis is manifested by pain, stiffness and tenderness resulting in slight limitation of motion, but not by limitation of the arm to the shoulder level or below. 2. For the entire appeal period, the Veteran's service-connected left ankle spurs is manifested by complaints of pain and stiffness and a moderate limitation of motion without a marked limitation of motion. 3. The Veteran does not currently have a right carpal tunnel disability. 4. The Veteran does not currently have a left carpal tunnel disability. CONCLUSIONS OF LAW 1. For the entire appeal period, i.e., since November 1, 2008, the criteria for an initial 10 percent rating, but no higher, for right shoulder and bicep tendonitis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5099-5024 (2013). 2. For the entire appeal period, the criteria for an initial 10 percent rating, but no higher, for left ankle spurs have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5099-5271 (2013). 3. A right carpal tunnel disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 4. A left carpal tunnel disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice 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; and (3) that the claimant is expected to provide. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A Supplemental Statement of the Case, when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In this appeal, the RO provided notice to the Veteran in an April 2008 letter, prior to the date of the issuance of the appealed January 2009 rating decision. The April 2008 letter explained what information and evidence was needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The Veteran was not provided with notice regarding effective dates. The Board finds, however, that any error in providing notice was nonprejudical to the Veteran. The Board concludes below that the preponderance of the evidence is against the Veteran's claims for entitlement to service connection for left and right carpal tunnel syndrome, and thus any questions as to the effective date to be assigned are rendered moot. Furthermore, for initial rating claims or claims for an earlier effective date, where, as here, service connection has been granted for right shoulder and bicep tendonitis; and left ankle spurs and the initial ratings and effective dates have been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement (NOD) with the rating or the effective date of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). 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 service, VA treatment records and the reports of May 2008 and March 2010 VA examinations. The examination reports reflect that the VA examiners who conducted these examinations reviewed the Veteran's past medical history, recorded her current complaints, conducted appropriate evaluations of the Veteran, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. As such, the Board finds that the May 2008 and March 2010 VA examination reports are sufficient upon which to base a decision with regard to these claims. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Also of record and considered in connection with the appeal are the various written statements provided by the Veteran and by the Veteran's representative. The Board finds that no additional RO action to further develop the record on the claims is warranted. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. I. Higher Initial Ratings. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during active service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2013). Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2013). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7 (2013). Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202, 205-206 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. The assignment of a particular Diagnostic Code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). In reviewing the claim for a higher rating, VA must consider which Diagnostic Code or Codes are most appropriate for application in the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). A. Right shoulder and bicep tendonitis In this case, the Veteran is currently assigned an initial noncompensable rating for right shoulder and bicep tendonitis prior to March 16, 2010, and a 10 percent rating, from March 10, 2010, pursuant to 38 C.F.R. § 4.130, Diagnostic Codes 5099-5024. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen; unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." Hence, the Veteran's right shoulder disability is rated by analogy, using the criteria for tenosynovitis under Diagnostic Code 5024. Diagnostic Code 5024 provides that tenosynovitis is rated on limitation of motion of the affected part as degenerative arthritis, which is addressed in Diagnostic Code 5003. Diagnostic Code 5003 for degenerative arthritis provides that arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. 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, x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of two or more major joints or two or more minor joints warrants a 10 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5201 provides that limitation of motion of the arm at the shoulder level is rated 20 percent for the major shoulder and 20 percent for the minor shoulder. Limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a. Under VA rating criteria, normal forward elevation (flexion) and abduction of the shoulder is from 0 degrees to 180 degrees, with 90 degrees being shoulder level; normal shoulder internal and external rotation is 0 degrees to 90 degrees, with 90 degrees being shoulder level. 38 C.F.R. § 4.71, Plate I. Factual Background An April 2008 treatment record noted that the Veteran presented with complaints of right shoulder pain for the past week. She had shoulder stiffness but no clicking sensation or catching upon movement. Her shoulder seemed "out of place" but was not unstable. There was right shoulder weakness. There was no swelling of the shoulder joint and no arthralgias. On examination, there was tenderness to palpation but there was no swelling, no erythema, no warmth, no atrophy and no deformity. No pain was elicited on motion and there was no pain elicited after the O'Brien's test. An apprehension (crank) test was negative. Sensory examination revealed no decreased response to tactile stimulation of the right shoulder and a motor examination demonstrated no weakness of the right shoulder. The diagnosis was tendonitis, bicipital and the Veteran was released without limitations. The Veteran underwent a VA examination in May 2008. The examiner noted that the Veteran injured her shoulder in 2000 and reinjured it last month when she fell. The Veteran reported that her right shoulder would swell at times and was painful, particularly with weather changes. She had a limited range of motion when it was painful. It was stable. There were no acute flares unless she over exercised. It did cause difficulty when she sat at her desk and typed. She treated the pain with Motrin and Flexeril. She did not engage in vigorous activities that involved her right arm. Examination of the right shoulder revealed no swelling or crepitus. Range of motion demonstrated abduction from 0 to 175 degrees. Adduction was from 0 to 40 degrees. Extension was from 0 to 40 degrees. Flexion was from 0 to 170 degrees. Internal rotation was from 0 to 90 degrees. External rotation was from 0 to 50 degrees. There was no change with repetitive testing and no symptoms produced by movements. X-ray of the right shoulder was negative. The diagnosis was tendonitis of the right shoulder. The Veteran underwent a VA examination in March 2010. She noted that her shoulder pain had been worsening and that she used Motrin for pain. Her shoulder continued to bother her and she could no longer sleep on her right side. She also noted pain with over-use. There was no deformity, giving way or instability of the right shoulder. There was pain, stiffness and weakness. There was no incoordination or decreased speed of joint motion. There were no episodes of dislocation or sublaxation, locking episodes or effusions. There was tenderness but this did not affect the range of motion. There was weakness (4+ out of 5 on strength test due to pain) and guarding. Flexion was from 0 to 180 degrees. Right abduction was from 0 to 180 degrees. Right internal rotation was from 0 to 90 degrees. Right external rotation was from 0 to 90 degrees. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions of range of motion. X-rays of the right shoulder were normal. The diagnosis was right shoulder rotator cuff tendonitis which resulted in problems with lifting and carrying as well as pain. Analysis As indicated previously, the Veteran has been assigned a noncompensable rating prior to March 16, 2010, and a 10 percent rating thereafter for the orthopedic manifestations of her right shoulder disability. However, the Board finds that an initial 10 percent rating, but no higher, for the entire appeal period, effective November 1, 2008, is warranted. A review of the evidence of record reflects that, for the entire appeal period, the Veteran's right shoulder and bicep tendonitis is manifested by pain, stiffness and weakness resulting in slight limitation of motion. In this regard, the May 2008 in-service VA examination reflects that the Veteran had minimal limitation of motion of the right shoulder with pain and stiffness as her flexion was from 0 to 170 degrees and her abduction was from 0 to 175 degrees. As noted above, normal forward elevation of a shoulder (flexion) as well as normal abduction (movement of the arm away from the side) are to 180 degrees. Given the foregoing evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that a 10 percent evaluation is warranted for the entire appeal period, i.e., (since November 1, 2008). Although the right arm was not limited to a compensable degree under Diagnostic Code 5201, the May 2008 VA examination did show some limitation of abduction and/or flexion. Furthermore, the Veteran reported that she had painful motion and functional shoulder difficulties, especially when lifting or working overhead. As the intent of the Rating Schedule is to recognize actually painful joints as entitled to at least the minimum compensable rating for the joint, 38 C .F.R. § 4.59, the Board finds that evidence of painful motion warrants an initial 10 percent rating since November 1, 2008. As for whether an evaluation in excess of 10 percent may be warranted during this time period, the evidence of record preponderates against finding a limitation of the right arm to the shoulder level, i.e., 90 degrees. At worse, abduction was limited to 170 degrees. With repetitive use, the examiners indicated that there was no additional limitation in range of motion. Thus, the criteria for an evaluation in excess of 10 percent have not been met. The Board acknowledges that the Veteran has pain, weakened movement and slightly less movement than normal. Furthermore, the Veteran is competent to report that her disability is worse than presently evaluated. In this regard, the Board accepts that she has functional impairment, pain and slightly limited motion of the right shoulder. See DeLuca, supra. The Board further finds that the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of impairment required for an initial higher evaluation in excess of 10 percent. With respect to other potentially applicable diagnostic codes, there is no evidence of any ankylosis, impairment of the humerus, or impairment of the clavicle or scapula. Hence, consideration of Diagnostic Codes 5200, 5202, and 5203 are not appropriate. 38 C.F.R. § 4.71a. In sum, from November 1, 2008, the Veteran met the criteria for a 10 percent evaluation for her right shoulder disability, but no higher. B. Left ankle spurs The Veteran's left ankle spurs disability has been evaluated as noncompensably disabling pursuant to 38 U.S.C.A. §38 C.F.R. § 4.71a, Diagnostic Codes 5003-5271. Under 38 C.F.R. § 4.71a , Diagnostic Code 5271, a 10 percent rating is warranted for a moderate limitation of ankle motion, and a 20 percent rating is assigned for a marked limitation. The normal range of motion of the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. Factual Background A June 2003 service treatment record noted that the Veteran had left ankle pain with activity and tenderness to palpation. A physical therapy note indicated that the Veteran had an unstable left ankle. A June 2004 service treatment record reported that the Veteran had sprained her ankle again. A September 2006 service treatment record noted that the left ankle had tenderness on palpitation. Anterior and Posterior drawer signs were observed. Abnormalities of the ankles were noted. Ankle motion was abnormal. Swelling was noted. There was no weakness, erythema, warmth or muscle spasm of the ankles. The diagnosis was an ankle sprain. An October 2006 service treatment record noted that the Veteran had ankle pain for the past 5 years as she had sprained her left ankle 3 times. She had mild spurring. Her range of motion was dorsiflexion from 0 to 15 degrees and plantar flexion from 0 to 45 degrees. The Veteran underwent a VA examination in May 2008. It was noted that the Veteran had a stress fracture of her ankle from running and was subsequently instructed to stop running. She had pain, swelling, instability and weakness of the left ankle but had full range of motion of the ankle. She wore a brace and experienced flares with activity which was problematic but did not affect her desk job. Examination of the ankle revealed no swelling or crepitus. Flexion was from 0 to 40 degrees. Supination was normal at 0 to 35 degrees. Pronation was from 0 to 15 degrees. There was no change with repetitive testing and movements did not cause any symptoms. X-rays of both feet and ankles were normal. No diagnosis was provided. The Veteran underwent a VA examination in March 2010. The Veteran reported that she sprained her ankle and has experienced repeated injuries to her ankle. She reported a dull throb in the ankle especially after walking long periods of time or exercising. She indicated that she was informed that she had arthritis in the ankle. There was no deformity, giving way, weakness, instability or incoordination. There was no decreased speed of joint motion or episodes of dislocation or sublaxation. There were no locking episodes, no effusions and no symptoms of inflammation. There were no flare-ups of joint disease. The Veteran had stiffness. There were no constitutional symptoms of arthritis. She was able to stand for 3 to 8 hours with only short periods of rest. There was no limitation to walking. She occasionally used a brace. Her gait was normal. There was no instability, no tendon abnormality and no abnormal angulation. Dorsiflexion was from 0 to 20 degrees. Left plantar flexion was from 0 to 40 degrees. There was no objective evidence of pain with active motion. There was no objective evidence of pain following repetitive motion and there were no additional limitations after three repetitions of range of motion. There was no joint ankylosis. X-rays of the left ankle were normal. The diagnosis was left ankle spurs with residuals. Analysis Given the foregoing evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that an initial 10 percent evaluation is warranted for the entire appeal period. The March 2010 VA examination demonstrated slight limitation of motion of the left ankle as left plantar flexion was from 0 to 40 degrees. Additionally, on VA examination in May 2008, the Veteran had pain, swelling, instability and weakness of the left ankle. While the May 2008 VA examiner noted a full range of motion and the March 2010 VA examiner noted that there was no objective evidence of pain with active motion, the Board will resolve reasonable doubt and assign a compensable 10 percent rating for her left ankle spurs. The Veteran's manifestations of her service-connected left ankle disability, however, have not approached the severity contemplated for an initial rating higher than 10 percent. As set forth above, in order for the Veteran's left ankle disability to warrant an evaluation in excess of 10 percent, the evidence must show a marked limitation of ankle motion. Clearly such a marked level of impairment is not demonstrated by the record as the May 2008 VA examiner noted that the Veteran had full range of motion and the March 2010 VA examination report reflected only slight limitation of motion as flexion was from 0 to 40 degrees. Indeed, even taking into account the Veteran's complaints of pain, the Board finds that a higher rating than 10 percent is not warranted as the March 2010 VA examiner noted that there was no objective evidence of pain with active motion, no objective evidence of pain following repetitive motion and no additional limitations after three repetitions of range of motion. Thus, there is no objective evidence that Veteran has functional loss or additional limitation of ankle motion due to pain, weakness, and atrophy of a severity to afford him an evaluation higher than 10 percent. See DeLuca; supra. The Board notes that the Veteran's representative's contentions regarding the March 2010 VA examination not taking place during the Veteran's flare-ups of her left ankle condition and thus not providing an accurate examination. However, on her March 2010 VA examination, it was noted that the Veteran was able to stand for 3 to 8 hours with only short periods of rest, had no limitation to walking, had a normal gait and had no objective evidence of pain with active motion. Therefore, even if the additional limitation of motion during such reported flare-ups were extreme, based on the reported functionality of the Veteran, the Board finds that the overall impairment resulting from her left ankle disability would still more closely approximate no more than a 10 percent rating. Given this evidence, entitlement to an evaluation in excess of 10 percent is not warranted at any time during the appeal period for right or left ankle spurs pursuant to 38 C.F.R. § 4.71a , Diagnostic Codes 5003- 5271. Accordingly, the Board finds that a 10 percent evaluation, but no higher, is warranted for left ankle spurs. C. Extraschedular Consideration The Board has considered the question of whether an extraschedular rating may be appropriate for the Veteran's service-connected right shoulder and bicep tendonitis; and left ankle spurs. See Bagwell v. Brown, 9 Vet. App. 157 (1966). Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent period of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.21(b) (1) (2012). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. The Veteran has not identified any factors which may be considered to be exceptional or unusual, and the Board has been similarly unsuccessful. Further, the record does not demonstrate any other reason why an extraschedular rating should be assigned. Accordingly, the Board therefore has determined that referral of the case for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b) (1) is not warranted. II. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Factual Background and Analysis The Veteran's December 1987 service entrance examination was negative for complaints or a history of carpal tunnel syndrome. In August 1992, the Veteran presented with right shoulder pain complaints that radiated down into her forearm. There was no particular injury that preceded this pain which she thought might have been related to her weight lifting. After not lifting weights for a week, she returned for a follow-up appointment and was pain free. A September 1992 service treatment record indicated that the Veteran had left shoulder pain that tingled down her left arm after a motor vehicle accident. The diagnosis was a muscle strain. A September 2006 service treatment record noted that the Veteran's neurological examination was normal. In July 2007, the Veteran presented with complaints of pain in her right forearm which occurred after she had begun swimming the day before. The impression was a right arm strain that was most likely a strain. In August 2007 the Veteran presented with complaints of right shoulder with tingling in her thumb. It was noted that he had an old possible right rotator cuff impingement. Sensory and motor examinations were normal. The impression was a "shoulder overuse injury" and "carpal tunnel". The Veteran was prescribed bilateral wrist splints. The Veteran underwent a VA examination in May 2008. The examiner noted that the Veteran had many other complaints involving the right wrist which would be addressed in other clinics. The Veteran underwent a VA examination in March 2010. The Veteran presented with complaints of pain and tingling in both of his hands that began in 2007 or 2008. She reported experiencing pain in her hands while using her Blackberry. She had swelling in both thumbs and paresthesias and pain in both thumbs that started in her thumb region but eventually involved her whole hand. Sensory examination was normal with the exception of decreased temperature sensation in both palms. Reflex examination was normal. Tinel's sign was absent bilaterally and Phalen's maneuver was negative bilaterally. Bilateral median and ulnar sensory nerve conduction studies (NCS) were normal. Bilateral transcarpal studies were normal. Bilateral median and right ulnar motor NCS were normal. The examiner concluded that this was a normal study and the EMG was negative for carpal tunnel syndrome. The diagnosis was paresthesia, not carpal tunnel syndrome. Problems associated with the diagnosis were pain and tingling of the hands. Neuralgia was present and the Veteran experienced decreased mobility, problems with lifting and carrying, weakness and pain. Under the circumstances of this case, the Board concludes that service connection for a bilateral carpal tunnel syndrome disability is not warranted as the Veteran has not been shown to have a current bilateral carpal tunnel syndrome disability. The Veteran's service treatment records clearly show that he had multiple complaints of pain and tingling of her hands and thumbs in service. Additionally, an August 2007 service treatment record noted that the Veteran had a "shoulder overuse injury" and "carpal tunnel". However, these in-service complaints appeared to be acute as there were no diagnoses of carpal tunnel syndrome since that time. Significantly, the August 2007 service treatment record also noted that sensory and motor examinations were normal. Furthermore, a review of the record is negative for any current diagnosed bilateral carpal tunnel syndrome disability. Notably, the VA examination in March 2010 noted that an EMG was negative for carpal tunnel syndrome as the current diagnosis was paresthesia, not carpal tunnel syndrome. Paresthesia "is an abnormal touch sensation, such as burning, prickling, or formication, often in the absence of an external stimulus." See Dorland's Illustrated Medical Dictionary 1371 (30th ed. 2003). The examiner also noted that the Veteran had neuralgia. The Board notes that neuralgia is defined as "pain extending along the course of one or more nerves." See Dorland's Illustrated Medical Dictionary 1251 (30th edition 2003). However, the Board notes that mere pain, alone, without a diagnosed or identifiable underlying malady or condition does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The Board observes that the Veteran's post service treatment records document that the Veteran has bilateral and wrist pain, but does not otherwise provide a diagnosis of a bilateral carpal tunnel syndrome disorder. Accordingly, the medical evidence of record does not support a current diagnosis of the claimed bilateral carpal tunnel syndrome disability. Hence, whereas here, the competent evidence establishes that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the instant appeal, the claim for service connection for a bilateral carpal tunnel syndrome disability must be denied because the first criterion for the grant of service connection-competent evidence of the disability for which service connection is sought-is not met. The Board notes the Veteran's contentions regarding the nature and etiology of her claimed bilateral carpal tunnel syndrome disability, as well as the evidence submitted by her and her representative contending that her claimed bilateral carpal tunnel syndrome disability is related to service. To the extent that the Veteran herself contends that a medical relationship exists between her current claimed disability and service, the Board acknowledges that the Veteran is competent to testify as to her observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that a bilateral carpal tunnel syndrome disability is not a disability subject to lay diagnosis. While some symptoms of the disorder may be reported by a layperson, the Veteran and her representative do not have the medical expertise to provide an opinion regarding its existence or etiology. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Thus, the Veteran and her representative's assertions that there is a relationship between her claimed bilateral carpal tunnel syndrome disability and her service are not sufficient in this instance and are outweighed by other probative evidence of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial 10 percent rating, but no higher, for service-connected right shoulder and bicep tendonitis is granted effective November 1, 2008, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial 10 percent rating, but no higher, for service-connected left ankle spurs is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for right carpal tunnel syndrome is denied. Entitlement to service connection for left carpal tunnel syndrome is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs