Citation Nr: 1415011 Decision Date: 04/07/14 Archive Date: 04/15/14 DOCKET NO. 10-23 785 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for meralgia paresthetica and neuropathy of the right thigh. 2. Entitlement to service connection for carpal tunnel syndrome of the left wrist. 3. Entitlement to service connection for diabetes mellitus, type II. 4. Entitlement to service connection for sleep apnea. 5. Entitlement to an initial rating in excess of 30 percent for anxiety and depression with pain disorder associated with right wrist disability. 6. Entitlement to an effective date earlier than February 20, 2007, for a 10 percent rating for a right wrist disability and earlier than July 1, 2007, for a 40 percent rating for the postoperative residuals of a right wrist surgical fusion. 7. Entitlement to an increased rating for a right wrist disability, in excess of 10 percent from February 20, 2007, to April 22, 2007; in excess of 40 percent from July 1, 2007, to August 7, 2007; and in excess of 40 percent from October 1, 2007. 8. Entitlement to an increased rating in excess of 10 percent for chondromalacia patella of the right knee. 9. Entitlement to an increased rating in excess of 10 percent for lateral meniscal chondrolcalcinosis of the left knee, until January 20, 2011, and in excess of 30 percent for a total left knee replacement from July 1, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from November 1977 to April 1979. This case comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Pittsburgh, Pennsylvania, Regional Office (RO) of the Department of Veterans Affairs (VA). In November 2008 correspondence, it appears that the Veteran has requested a total disability rating by reason of individual unemployability due to service connected disabilities. The Veteran has also raised the issue of entitlement to an increased rating for right wrist carpal tunnel syndrome. These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of service connection for meralgia paresthetica and neuropathy of the right thigh, carpal tunnel syndrome of the left wrist, sleep apnea and diabetes mellitus type II; and the issues of increased ratings for left and right knee disabilities and anxiety and depression with pain disorder associated with right wrist disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. In a June 1979 rating decision, the RO granted service connection for right wrist strain and awarded a noncompensable disability evaluation. The noncompensable disability evaluation was confirmed and continued by rating decision of the RO dated in March 2003. The Veteran did not appeal these decisions after notification, and they became final. 2. On February 20, 2007, the RO received the Veteran's claim for an increased rating for right wrist strain. 3. VA outpatient records, dated on December 28, 2006, showing treatment for the Veteran's increased complaints of right wrist pain, constitute an informal claim for increased rating. 4. On April 23, 2007, the Veteran underwent several surgical procedures on the right wrist, including right wrist posterior interosseous neurectomy, right wrist scaphoidectomy, and right wrist four-corner fusion; a total convalescent rating was awarded from April 23, 2007 through June 30, 2007; the Veteran did not submit disagreement with the effective date of the convalescent rating. 5. The Veteran is left handed. 6. As of December 28, 2006, the Veteran's right wrist disability was primarily manifested by pain and limitation of motion. 7. As of July 1, 2007, the Veteran's right wrist disability is primarily manifested by ankylosis at an unfavorable angle. CONCLUSIONS OF LAW 1. The criteria for an effective date of December 28, 2006, for the award of a 10 percent disability rating for a right wrist sprain have been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.102, 3.155, 3.157, 3.158, 3.159, 3.400 (2013). 2. The criteria for an effective date earlier than July 1, 2007, for the award of a 40 percent disability rating for residuals of surgical fusion of the right wrist are not met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.1, 3.155, 3.157, 3.159, 3.400 (2013). 3. The criteria for an increased rating in excess of 10 percent for right wrist strain were not met from December 28, 2006, to April 23, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2013). 4. The criteria for an increased rating in excess of 40 percent for residuals of surgical fusion of the right wrist were not met for any period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable AOJ jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Regarding the claim for an earlier effective date for awards of right wrist disability ratings, as the rating decisions on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess 19 Vet. App. at 490. Regarding the claim for increased rating for right wrist disability, in a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded a medical examination of the right wrist most recently in January 2010. The Board finds that the opinion obtained is adequate. The opinion was provided by a qualified medical professional and was predicated on a full reading of all available records. The examiner also provided a detailed rationale for the opinion rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2013). The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F.3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Earlier Effective Dates The Veteran seeks an effective date earlier than February 20, 2007 for the award of a 10 percent disability rating for right wrist strain, and an effective date earlier than July 1, 2007, for a 40 percent rating for residuals of a surgical fusion of the right wrist. Review of the record shows that these rating were assigned in a December 2007 rating decision. It is noted that awards of temporary total disability ratings based on surgeries performed in July and August 2007 were also assigned in the December 2007 rating decision. The Veteran has not appealed these awards. An award based on a claim for an increase of compensation "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." See 38 U.S.C.A. § 5110(a) (West 2002). In other words, an increased rating may be assigned on the "date of receipt of claim or date entitlement arose, whichever is later." See 38 C.F.R. § 3.400(o)(1) (2013). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See 38 C.F.R. § 3.1(p) (2013). Any communication or action indicating an intent to apply for VA benefits and identifying the benefit sought from a claimant or representative may be considered an informal claim. See 38 C.F.R. § 3.155(a) (2013). VA is required to identify and act on informal claims for benefits. See 38 U.S.C.A. § 5110(b)(3) (West 2002); 38 C.F.R. §§ 3.1(p), 3.155(a) (2013). VA is not required to anticipate any potential claim for a particular benefit when no intention to raise it was expressed. See Brannon v. West, 12 Vet. App. 32, 35 (1998); Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995). Once a formal compensation claim has been allowed, receipt of certain medical evidence will be accepted as an informal claim for an increased rating. See 38 C.F.R. § 3.157(b) (2013). Such evidence includes a report of VA outpatient or hospital examination or report of admission to a VA hospital. See 38 C.F.R. § 3.157(b)(1) (2013). When the evidence in question is VA medical evidence, the effective date of the claim is the date of treatment. Id. These provisions apply only when such reports relate to examination or treatment of a service-connected disability or when a claim specifying the benefit sought is received within one year from the date of the examination, treatment, or admission. Id. When medical evidence is from a private physician, the effective date of the claim will be the date of receipt of such evidence. See 38 C.F.R. § 3.157(b)(2) (2013). In the instant case, a June 1979 rating decision granted service connection for a right wrist strain and assigned a zero percent (noncompensable) evaluation effective in April 1979. The rating of the Veteran's right wrist disability was re-evaluated, but confirmed and continued as zero percent, by March 2003 RO rating decision. A rating decision becomes final and binding if the veteran does not timely perfect an appeal of the decision. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.302, 20.1103. The Veteran did not appeal these decisions, and they became final. Id. No further correspondence or evidence was received from the Veteran regarding his right wrist until February 20, 2007, when the Veteran filed a claim for an increased rating for his right wrist disability along with private treatment records dated in January and February 2007. In May 2007, the Veteran submitted additional evidence, including a March 2007 treatment records and an April 2007 operative report, received in May 2007, showing that the Veteran underwent several procedures, including right wrist posterior interosseous neurectomy, right wrist scaphoidectomy, right wrist four-corner fusion with hubcap plate and cancellous bone graft, harvesting of cancellous bone graft of the right distal radius, and a right carpal tunnel release. The Board has reviewed the record to determine whether any evidence exists to indicate that VA received an informal claim for an increased rating before the date the Veteran's claim was received, February 20, 2007. There are no lay statements, but a VA treatment record dated on December 28, 2006 shows that the Veteran had complaints of right wrist pain that had been worsening over the past two years. This is the only VA medical evidence of record that relates to the Veteran's right wrist from the time the noncompensable rating was confirmed and continued in March 2003 until the February 2007 claim was received by VA. Other VA medical evidence relates to the Veteran's service-connected knee disabilities. Thus, resolving reasonable doubt in the Veteran's favor, the December 28, 2006, treatment record represents an informal claim for increase in the Veteran's right wrist disability. To this extent the appeal is granted. Regarding the effective date of the 40 percent rating increase, July 1, 2007, as noted the Veteran underwent significant surgery on April 23, 2007. A 100 percent temporary total rating was awarded on the basis of surgery requiring convalescence under the provisions of 38 C.F.R. § 4.30. This regulation provides that a total disability rating will be assigned following surgery requiring convalescence. The rating will be continued for a period of 1, 2, or 3 months from the first day of the month following hospitalization or outpatient release. The Veteran did not disagree with the period assigned for convalescence of this rating, only the convalescent rating assigned after additional surgery was necessitated in August 2007. The notice of disagreement that he submitted in February 2008 requested only that this second convalescent rating be extended to October 1, 2007. This was reflected in the rating. Under these circumstances, the 40 percent award is effective from the cessation of the temporary total convalescent rating, or July 1, 2007. That the Veteran required additional surgery is reflected in the assignment of another convalescent rating, effective August 8, 2007, the date of the surgical revision, which was continued to September 30, 2007. While it is noted that the Veteran disagreed with the October 2007 date assigned in the December 2007 rating, his notice of disagreement was not received by VA until November 2009, such that it was not timely filed. Hence this issue is not properly before the Board. 38 U.S.C.A. §§ 7105, 7108 (West 1991); 38 C.F.R. § 20.302(c) (1997); Roy v. Brown, 5 Vet. App. 554 (1993). A further extension of the convalescent rating was denied by a January 2010 rating decision of the RO that was not appealed by the Veteran. Finally, the Board notes that when a rating decision is final, only a request for a revision premised on CUE could result in the assignment of earlier effective dates. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). The Veteran has not filed a claim for CUE in any of the prior rating decisions and the Board does not recognize any error in those determinations. A freestanding claim for earlier effective dates, once the decision becomes final, attempts to vitiate the rule of finality. The claimant had one year from notification of the prior rating decisions to initiate an appeal by filing a notice of disagreement with those decisions, and they became final when an appeal was not perfected within the allowed time period. Increased Rating for Right Wrist Disability Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2013). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims decided herein. Service connection for a right wrist strain was granted by the RO in a June 1979 rating decision. A noncompensable rating was assigned under Code 5215. The rating was increased to 10 percent under Code 5214 by RO rating decision in December 2007, and then to 40 percent effective July 1, 2007 under the same Code. (The convalescent ratings assigned from April 23, 2007, to June 30, 2007, and from August 8, 2007, to September 30, 2007, are not part of the current appeal.) Normal ranges of motion of the wrist are dorsiflexion from 0 degrees to 70 degrees, and palmar flexion from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5214 provides ratings for ankylosis of the wrist. Favorable ankylosis of the wrist in 20 degrees to 30 degrees dorsiflexion is rated 30 percent disabling for the major wrist and 20 percent for the minor wrist; ankylosis of the wrist in any other position except favorable is rated 40 percent disabling for the major wrist and 30 percent for the minor wrist; and unfavorable ankylosis of the wrist in any degree of palmar flexion, or with ulnar or radial deviation, is rated 50 percent disabling for the major wrist and 40 percent for the minor wrist. 38 C.F.R. § 4.71a. A Note provides that extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. 38 C.F.R. § 4.71a. Diagnostic Code 5215 provides ratings based on limitation of motion of the wrist. Limitation of palmar flexion in line with the forearm is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist; limitation of dorsiflexion to less than 15 degrees is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist. 38 C.F.R. § 4.71a. More generally, 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. In addition, 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. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. Thus, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The Court has also held that VA's regulations pertaining to whether a compensable rating is warranted for pain (as shown by adequate pathology and evidenced by the visible behavior in undertaking motion), 38 C.F.R. §§ 4.40 and 4.59, apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2013). By definition, ankylosis contemplates a total absence of joint mobility. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) and Lewis v. Derwinski, 3 Vet. App. 259 (1992) (both indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). The Veteran contends that his right wrist disability is more disabling than currently evaluated. He has asserted that, while he has described himself as being left hand dominant, he is actually ambidextrous so that his right hand should be considered his major upper extremity under the provisions of 38 C.F.R. § 4.69. He also contends that an additional rating should be awarded for neurologic symptoms of the right upper extremity so that a total 30 percent evaluation should be assigned. He also believes that, because he has arthritis of two separate joints (the right wrist and right knee) a 20 percent rating is warranted under the provisions of Code 5003. VA outpatient treatment records dated on December 28, 2006; show that the Veteran was seen for right wrist pain with history of fracture in the past and likely osteoarthritis of the wrist. He was to be sent to his private physician for consultation. Private treatment records show that in January 2007, the Veteran complained of increasing diffuse right wrist discomfort with some numbness and tingling through the hand. Heavier activity caused a dull constant ache with significant discomfort. Examination showed no swelling, ecchymosis or erythema. Right wrist motion was diminished in all planes when compared to the left. Tinel's maneuver was markedly positive. There was no gross sensory deficit and motor function seemed to be reasonably maintained. There was crepitance with wrist motion. X-ray studies showed early degenerative change about the right wrist. The impression was right wrist pain with instability sensations, numbness, and tingling; rule out carpel tunnel syndrome. Private treatment records dated in February 2007 noted that the Veteran had undergone electrodiagnostic studies that showed carpel tunnel syndrome. Examination continued to show diminished motion in all planes. There was no obvious sensory deficit and motor function was well maintained. There was some crepitance of the wrist with motion. The contralateral wrist and hand were unremarkable. In March 2007, examination showed trace effusion, but no erythema or warmth. Range of motion showed dorsiflexion to 50 degrees, palmar flexion to 60 degrees, pronation to 90 degrees, supination to 90 degrees and radial and ulnar deviation to 40 degrees. He complained of pain, particularly with flexion and extension. Tinel's sign was positive as was Phalen's test against gravity. There was no atrophy of the thenar eminence, hypothenar eminence or intrinsic hand musculature. Grip strength was well maintained. It is initially noted that, despite the Veteran's assertions that he is ambidextrous, the evidence shows that he is left-handed. In this regard, it is noted that the Veteran reported that his left was his dominant hand on examination for entry into active duty in 1977. During a VA occupational therapy consultation in November 2007, the Veteran again reported that his left hand was his dominant hand. On examination by VA in January 2010, the Veteran is also described as being left hand dominant as far as writing. These admissions by the Veteran are found to be most persuasive so that the Board finds that the Veteran's right hand is his minor upper extremity. The examinations of record prior to the Veteran's April 2007 surgery, show some limitation of motion of the right wrist, which is sufficient for the 10 percent rating that has been assigned, but no evidence demonstrating that he met the criteria for a rating in excess of 10 percent prior to his surgery. In this regard, it is noted that, for an increased rating, ankylosis of the right wrist joint would have to be demonstrated. While motion may be shown to be limited, absence of motion is not demonstrated. While the Veteran contends that a rating should be assigned for neurologic symptoms of the right hand, he is currently in receipt of a separate 10 percent rating for right wrist carpal tunnel syndrome. Interpreting his statements as a request for a higher rating based on neurologic symptoms, the Board has referred the issue of entitlement to an increased rating for right wrist carpal tunnel syndrome to the RO for action deemed appropriate. The Veteran also contends that a separate 20 percent rating is warranted on the basis of degenerative arthritis under Code 5003. This code provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. As limitation of motion of the Veteran's right wrist has been demonstrated and utilized as the basis for the 10 percent rating that was assigned, this diagnostic criterion is not for application. Following the April 2007 surgery, that included fusion of the right wrist joint, a May 2007 VA treatment record showed that the range of motion was very stiff. X-rays showed a hubcap plate over the four-corner fusion with excellent placement of the screws and no change in position. In July 2007, palpation of the right wrist was tender dorsally along the distal edge of the carpal bones. Wrist motion was decreased to perhaps 10 degrees of dorsiflexion, 10 degrees of volar flexion, both of which were limited secondary to discomfort. In August 2007, the Veteran underwent a revision of the right wrist four corner fusion with iliac crest bone graft and screw fixation. The hubcap plate that had been inserted was removed and an iliac crest bone graft harvested. An examination was conducted by VA in January 2010. It was reported that electrodiagnostic studies showed moderate right carpal tunnel syndrome. He complained of some numbness feeling in the right hand fingertips. As far as interference with his activities of daily living (ADLs) he remained independent, although his right wrist could not lift or manipulate heavy objects. On examination, it was noted that the right wrist was fused so that there was no active range of motion in the joint. The Veteran is currently receiving the maximum schedular evaluation for ankylosis of the minor extremity at an unfavorable angle under the applicable regulations. The Veteran has argued that he should be rated for loss of use of the right hand due to his right wrist disability. As noted, extremely unfavorable ankylosis of the wrist will be rated as loss of use of the hand under Diagnostic Code 5125. Diagnostic Code 5125 assigns a 70 percent rating for loss of use of the hand of the major upper extremity and a 60 percent rating for loss of use of the hand of the minor upper extremity. 38 C.F.R. § 4.71a. Loss of use of the hand will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump with a suitable prosthetic appliance. Note (f) following Diagnostic Code 5151. In the present case, at a January 2010 VA peripheral nerves examination, it was noted that the Veteran cannot lift or manipulate heavy objects secondary to the right wrist fusion procedure. On examination, there was normal muscle recruitment in both hands and no atrophy. He was able to oppose every digit to the thumb of both hands. His right hand showed decreased motion because of his right wrist fixation, but the fingers were all normal moving. These findings demonstrate essentially normal use of the hand, as there was no muscle atrophy and normal movement of the fingers. It is recognized that the wrist is surgically fused, but the current 40percent rating adequately compensates the Veteran for this functional impairment. It is clear that he has greater function than that which would be equally well served by an amputation stump and suitable prosthesis. Therefore, an increased rating based on loss of use of the hand is not warranted. It can be argued that a higher rating should be assigned on an extraschedular basis under 38 C.F.R. § 3.321(b)(1). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2013); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must 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 VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. In this case, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal periods under consideration is contemplated by the rating schedule. The Veteran's right wrist disability was manifested by limitation of motion prior to his April 2007 surgery, which directly corresponds to the schedular criteria for a 10 percent evaluation. This also incorporates various orthopedic factors that limit motion or function of the wrist. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. After the surgery, the Veteran is rated as unfavorable ankylosis of a minor extremity, which is specifically contemplated in the schedular rating criteria. For these reasons, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's right wrist disability, and no referral for an extraschedular rating is required. ORDER The effective date for an award of a 10 percent rating for a right wrist strain is December 28, 2006. To this extent the benefit is granted, subject to controlling regulations applicable to the payment of monetary benefits. An effective date earlier than July 1, 2007, for an award of a 40 percent rating for residuals of a right wrist fusion is denied. A rating in excess of 10 percent for right wrist strain from December 28, 2006, to April 22, 2007, is denied. A rating in excess of 40 percent for residuals of a right wrist fusion from July 1, 2007, is denied. REMAND Regarding the Veteran's claims of service connection for diabetes mellitus, type II, carpel tunnel syndrome of the left wrist, meralgia paresthetica and neuropathy of the right thigh, and sleep apnea, it is noted that the Veteran's main contentions are that these disabilities are caused or aggravated by his service-connected disabilities. Medical opinions that generally support these contentions have been submitted for diabetes mellitus, sleep apnea, and left carpal tunnel syndrome, but the statements do not offer the necessary specificity or rationale as support. The Veteran has not been afforded a VA examination regarding the contentions and this is found by the Board to be necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (Setting forth the criteria under which VA is required to obtain an examination.) Although the Veteran was afforded an examination of meralgia paresthetica and neuropathy of the right thigh, which resulted in a negative nexus opinion, it is noted that the examiner did not advance an opinion as to whether it was at least as likely as not that this disability was aggravated by a service-connected disability. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). As the possibility of aggravation has not been addressed, an additional examination is found to be necessary. Regarding the evaluation of each of the Veteran's knees, review of the record shows that the Veteran was last afforded a VA examination in January 2009. He has contended that since that examination, his right knee has worsened and he has had a total left knee replacement. He contends that a 60 percent rating is warranted for the left knee as he has severe painful range of motion with swelling. It is believed that an examination is necessary to ascertain the current status of the Veteran's knee disabilities. With regard to increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). Regarding the Veteran's claim of initial rating in excess of 30 percent for anxiety and depression with pain disorder associated with right wrist disability, it is noted that, while the Veteran was afforded a VA examination in January 2009, the examination report noted the Veteran's disability level to be represented by a GAF score of approximately 55, which, it was stated, was assigned based on that portion of anxiety and depression associated with the Veteran's physical limitations. The examiner went on to state that if depression and anxiety from other non-service related issues and stressors were to be taken into account, the Veteran's GAF score would be lower. If the Veteran's service-connected psychiatric symptoms have not been differentiated from his nonservice-connected psychiatric symptoms, all of the Veteran's psychiatric symptoms and their severity must be considered. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). As such, an additional examination is deemed necessary by the Board. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be contacted and asked to identify all pertinent treatment records, VA and non-VA, which have not previously been obtained. Following any necessary consent from the Veteran, the records of such treatment should be obtained and added to the claims folder or electronic record. 2. The RO/AMC should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of his left carpal tunnel syndrome. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (probability 50 percent or more) that the left carpal tunnel syndrome is related to service, or is proximately due to or aggravated by a service-connected disability, including overuse syndrome as opined by the Veteran's private physician. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 3. The RO/AMC should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of his sleep apnea. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (probability 50 percent or more) that sleep apnea is related to service, or is proximately due to or aggravated by a service-connected disability. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 4. The RO/AMC should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of his diabetes mellitus type II. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (probability 50 percent or more) that diabetes mellitus, type II, is related to service or is proximately due to or aggravated by a service-connected disability. The examiner should be requested to specifically address contentions that the Veteran's glucose levels in service may have represented early manifestations of diabetes mellitus. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 5. The RO/AMC should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of his meralgia paresthetica and neuropathy of the right thigh. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (probability 50 percent or more) that the meralgia paresthetica and neuropathy of the right thigh is related to service or is proximately due to or aggravated by a service-connected disability. The examiner should specifically address whether the donor site surgery for his service-connected right wrist disability caused or aggravated the right thigh disability. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 6. The RO/AMC should arrange for the Veteran to undergo a mental disorders examination to ascertain the current severity of his service-connected anxiety and depression with pain disorder associated with right wrist disability. All necessary special studies or tests are to be accomplished. The claims folder should be made available to the examiner for review in connection with the examination. If possible, a Global Assessment of Functioning score attributable solely to the service-connected anxiety and depression with pain disorder should be assigned. The examiner is then requested to offer an opinion as to whether and to what degree the Veteran's service-connected anxiety and depression with pain disorder renders him incapable of obtaining and maintaining gainful employment. For any psychiatric disorder(s) other than his service-connected anxiety and depression with pain disorder that is identified, the examiner should state what, if any, additional disability is associated with those disabilities. All opinions should be supported by a written rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. The RO/AMC should arrange for the Veteran to undergo a medical examination to ascertain the current nature severity of his service-connected knee disabilities. The claims folder should be made available to the examiner for review in connection with the examination. X-rays and/or other diagnostic studies should be done, as deemed appropriate by the examiner. The examiner must provide a thorough description of the appellant's service-connected disorders and render objective clinical findings concerning the severity of the disabilities, to include observations of pain on motion, deformity, excess fatigability, incoordination, weakened movement and other functional limitations, if any. The examiner must then render an opinion concerning the effect of the appellant's service-connected knee disabilities on his ordinary activity and his ability to procure and maintain employment. 8. Thereafter, the RO/AMC should readjudicate the issues on appeal. If any determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claims for benefits. They should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2013). 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. 2013). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs