Citation Nr: 1539309 Decision Date: 09/14/15 Archive Date: 09/24/15 DOCKET NO. 10-22 118 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an initial rating higher than 10 percent for a right wrist disability. 2. Entitlement to a compensable rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty from February 1960 to October 1964. This matter is before the Board of Veterans' Appeals (Board) on appeal of a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, that granted service connection and a 10 percent rating for a right wrist disability (degenerative joint disease of the right wrist, status post-surgical repair), effective March 15, 2007. By this decision, the RO also denied a compensable rating for bilateral hearing loss. The Veteran withdrew a request for a Board hearing in August 2014. In November 2014, the Board remanded this appeal for further development. In an April 2015 statement, the Veteran appeared to raise issues of entitlement to service connection for disorders due to exposure to Agent Orange. The Veteran did not list the issues, but he referred to issues that had previously been denied. Any such issues are not before the Board at this time and are referred to the RO for appropriate action. The issue of entitlement to a compensable rating for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the agency of original jurisdiction. FINDING OF FACT Since the effective date of service connection on March 15, 2007, the Veteran's right wrist disability (major upper extremity) is manifested by no more moderate incomplete paralysis of the median nerve, as well as some limitation of motion with arthritis, but no malunion of the ulna and radius, and no ankylosis. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for the orthopedic manifestations of a right wrist disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5210, 5211, 5212, 5213, 5214, and 5215 (2015). 2. The criteria for a separate initial 30 percent rating, but no higher, for the neurologic manifestations of a right wrist disability have been met since service connection for that disorder became effective on March 15, 2007. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2015). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide notice of the information and evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). A standard May 2007 letter satisfied the duty to notify provisions for the underlying service connection claim for the right wrist. In any case, the appeal arises from a disagreement with the initially assigned disability rating after service connection was granted. Once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice is no longer required because the claim has already been substantiated. VA also has a duty to provide assistance to substantiate a claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c). The Veteran's service treatment records have been obtained. Post-service VA and private treatment records have also been obtained. Pursuant to the Board's November 2014 remand, the Veteran was asked to identify any other records that may be relevant to the claim. He did not respond to the request. The Veteran was provided with VA examinations in May 2007 and June 2012. Pursuant to the Board's November 2014 remand, the Veteran was also provided with a VA examination in March 2015. The examinations are sufficient evidence for deciding the claim. The reports are adequate as they are based upon consideration of the Veteran's prior medical history and examinations, describe the disability in sufficient detail so that the Board's evaluation is a fully informed one, and contain reasoned explanations. Thus, VA's duty to assist has been met for the right wrist claim. II. Legal Criteria Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (2014); 38 C.F.R. Part 4 (2015). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 (2015). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2015). The Board will consider entitlement to staged ratings to compensate for times during the rating period when the disability may have been more severe than at other times during the course of the rating period on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). 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. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2015). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 592. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention 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. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. For the purpose of rating disability from arthritis, the spine is considered a major joint. 38 C.F.R. § 4.45. Degenerative or traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints or joint involved. When there is arthritis and at least some limitation of motion, but the limitation of motion would be rated noncompensable under a limitation of motion code, a 10 percent rating may be assigned for each affected major joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2014). It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2015). The Veteran's right arm is his major upper extremity. For the major upper extremity, Diagnostic Code 5210 provides a 50 percent rating for nonunion of the radius and ulna, with flail joint. 38 C.F.R. § 4.71a, Diagnostic Code 5210. For the major upper extremity, Diagnostic Code 5211 provides a 10 percent rating for malunion of the ulna with bad alignment, a 20 percent rating for nonunion of the ulna in the lower half, a 30 percent rating for nonunion of the ulna in the upper half, with false movement, without loss of bone substance or deformity, and a 40 percent rating for nonunion of the ulna in the upper half, with false movement, with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5211. For the major upper extremity, Diagnostic Code 5212 provides a 10 percent rating for malunion of the radius with bad alignment, a 20 percent rating for nonunion of the radius in the upper half, a 30 percent rating for nonunion of the radius in the lower half, with false movement, without loss of bone substance or deformity, and a 40 percent rating for nonunion of the radius in the lower half, with false movement, with loss of bone substance (1 inch or more) and marked deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5212. The maximum rating for limitation of motion of the wrist is 10 percent, and such is assigned when dorsiflexion is less than 15 degrees or where palmar flexion is limited in line with the forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5215. A rating in excess of 10 percent for a wrist disability is available only where it is shown that there is wrist ankylosis of a specified degree. 38 C.F.R. § 4.71a, Diagnostic Code 5214. Limitation of supination of a forearm is rated 10 percent when limited to 30 degrees or less. Limitation of pronation of the major forearm is rated 20 percent when motion is lost beyond the last quarter of arc and the hand does not approach full pronation, and 30 percent when motion is lost beyond the middle of the arc. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Under 38 C.F.R. § 4.71a, a note indicates that in all forearm and wrist injuries, Diagnostic Codes 5205 through 5213, multiple impaired fingers movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed the rating for loss of use of the hand. Normal wrist motion consists of 70 degrees of dorsiflexion (extension), 80 degrees of palmar flexion, 45 degrees of ulnar deviation, and 20 degrees of radial deviation. 38 C.F.R. § 4.71, Plate I. The Veteran is also service connected for a laceration scar of the right wrist. The only issue currently on appeal is entitlement to an initial rating higher than 10 percent for a right wrist disability. Therefore, the Board will solely address that issue. Additionally, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Note: Combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. Diagnostic Code 8515 pertains to paralysis of the median nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8515. As noted above, the evidence in this case indicates that the Veteran is right handed. Therefore, the Board will apply the criteria applicable to the major extremity. 38 C.F.R. § 4.69 (2015). The criteria for evaluating the severity or impairment of the median nerve is set forth under Diagnostic Codes 8515, 8615, and 8715. Under Diagnostic Code 8515, complete paralysis of the median nerve is where the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand ; pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition of abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. This code provides a 10 percent rating for mild incomplete paralysis of the median nerve. A 30 percent rating is warranted for moderate incomplete paralysis of the median nerve in the major extremity. A 50 percent rating is warranted for severe incomplete paralysis of the median nerve in the major extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Diagnostic Codes 8615 and 8715 address the criteria for evaluating neuritis and neuralgia of the median nerve, respectively. The criteria are consistent with the criteria for evaluating degrees of paralysis as set forth above. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715 (2015). III. Factual Background Private and VA treatment records dated from May 2006 to April 2007 show that the Veteran was treated for multiple disorders. At a May 2007 VA examination, the Veteran reported that he had swelling in the right wrist after use, as well as aching all along the palmar aspect of the wrist. He also stated that his right wrist felt weak and that it lacked strength. The Veteran indicated that he could not use his right wrist for an extended period of time, to include when he was writing or using power tools. The examiner reported, as to range of motion of the Veteran's right wrist, that dorsiflexion was 70 degrees; palmar flexion was 80 degrees, with pain at 80 degrees; radial deviation was 20 degrees; and that ulnar deviation was 45 degrees, with pain at 45 degrees. The examiner indicated that following repetitive use, the Veteran's right joint function was additionally limited by pain, and that the pain had a major functional impact. The examiner stated that following repetitive use, the right joint function was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. It was noted that there was no additional limitation of motion of joint function. The examiner indicated that an x-ray, as to the Veteran's right wrist, showed mild arthritic changes in the radiocarpal joint. It was noted that metallic wire was seen in the soft tissues anterior to the distal radius and proximal carpal rows. The examiner indicated that the diagnosis was a laceration to the right wrist with laceration of the flexor profundus, status post-surgical repair, with scars, and degenerative joint disease of the right wrist. The examiner stated that, subjectively, the Veteran reported that he had right wrist weakness and swelling if it was over-used with writing, typing, or using tools. The examiner maintained that there was also mild pain on range of motion of the right wrist. Private and VA treatment records dated from October 2007 to May 2012 indicate that the Veteran was treated for multiple disorders, including right wrist problems. A June 2012 VA examination report noted that the Veteran reported that he had pain on activity with his right wrist. He stated that he used Advil on a daily basis. He indicated that nothing in particular aggravated his right wrist, but that driving would tend to aggravate it. The Veteran maintained that he used a wrist brace which helped. He stated that increased motion, especially dorsiflexion, would also aggravate his right wrist disability. The Veteran reported that he had a small area just above the flexor crease that was very sensitive to pressure. It was noted that there were no flare-ups and no limitations of activities of daily living. The Veteran stated that he retired in 1996. The examiner reported that the Veteran was right hand dominant. As to range of motion of the Veteran's right wrist, the examiner indicated that dorsiflexion was 20 degrees and that painful motion began at 20 degrees, and that palmar flexion was 60 degrees and that painful motion began at 60 degrees. The examiner stated that the Veteran was able to perform repetitive use testing with three repetitions. The examiner indicated that post-repetitive use testing range of motion was 20 degrees of dorsiflexion and 60 degrees of palmar flexion. The examiner maintained that the Veteran had palpable crepitus with range of motion testing. It was noted that the Veteran did not have additional limitation of range of motion in the right wrist after repetitive use testing. The examiner reported that the Veteran did have functional loss and/or functional impairment of the right wrist. The examiner indicated that the Veteran had less movement than normal and pain on movement. It was noted that the Veteran had tenderness or pain on palpation of the joints and soft tissue of the right wrist. The examiner stated that muscle strength testing of the right wrist was 5/5 with flexion and extension. The examiner reported that the Veteran did not have ankylosis of the right wrist. It was noted that the Veteran had also not undergone a wrist joint replacement. The examiner indicated that the Veteran did undergo arthroscopic surgery of the right wrist. The examiner stated that the Veteran sustained a laceration of the right wrist during service and that he underwent to surgeries to repair the tendon and a fracture of his wrist. The examiner maintained that the Veteran had current residuals of decreased range of motion; decreased sensation of the index, middle, and on the radial side of the ring finger. The examiner indicated that there was not functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation or prosthesis. The examiner reported that imaging studies of the right wrist showed degenerative or traumatic arthritis. The actual June 2012 x-ray, as to the Veteran's right wrist, related an impression of no acute abnormalities, with surgical sutures in the volar soft tissues of the wrist, and degenerative changes in the first metacarpocarpal and metacarpophalangeal joints. It was noted that there was a deformity of the distal navicular. The diagnoses were degenerative joint disease of the right wrist and a flexor tendon laceration, with a possible fracture wrist, on the right. The examiner indicated that the Veteran's right wrist disability did not impact his ability to work. VA treatment records dated from June 2012 to January 2013 refer to continued treatment. A March 2015 VA wrist conditions examination report included a notation by the examiner that all medical records and details of the Veteran's injury had been reviewed. The Veteran reported that he still had pain and weakness in his right hand. It was noted that the Veteran's right hand was the dominant hand. The Veteran indicated that he had flare-ups that impacted the function of his right wrist. He stated that flare-ups would involve increased pain and that they would occur thirty to forty times per year. He maintained that the flare-ups would last for an hour and that they caused moderate limitation of activity. As to range of motion of the Veteran's right wrist, the examiner reported that dorsiflexion was 20 degrees and that painful motion began at 20 degrees, and that palmar flexion was 50 degrees and that painful motion began at 50 degrees. The examiner also indicated that ulnar deviation of the right wrist ended at 10 degrees and that painful motion began at 10 degrees, and that radial deviation ended at 10 degrees and that painful motion began at 10 degrees. The examiner maintained that the Veteran was not able to perform repetitive use testing with three repetitions due to pain. It was noted that the Veteran did not have additional limitation in range of motion of the right wrist following repetitive use testing. The examiner indicated that the Veteran did have functional loss and/or function impairment of the right wrist in that he had weakened movement, excess fatigability, and pain on movement. The examiner stated that the Veteran's weakness and fatigability of the right wrist significantly limited his functional ability during flare-ups, or when the joint was used repeatedly over a period of time. It was noted that the Veteran was unable to replicate the estimated limitation at the time of the examination. The examiner reported that the Veteran had localized tenderness or pain on palpation of the joints and soft tissues of his right wrist. The examiner indicated that muscle strength testing of the right wrist was 2/5 with flexion and extension. The examiner stated that the Veteran did not have ankylosis of the right wrist. It was noted that the Veteran had also not undergone a wrist joint replacement. The examiner indicated that the Veteran did not undergo arthroscopic surgery of the right wrist. The examiner related that there was not functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation or prosthesis. The examiner reported that imaging studies of the right wrist were not performed. The diagnoses were laceration of the flexor profundus, right, with surgical repair and a residual scar, and trigger finger of the right thumb. The examiner also indicated that the Veteran had enthesopathy which was arthritis of the tendon and joints and that such diagnosis was a progression of the original injury to the tendon. The examiner stated that the Veteran had a traumatic rupture of the flexor profundus and that there was decreased flexion of the right wrist, as well as crepitus in the joint that was due to posttraumatic sequelae. The examiner indicated that the Veteran had mild paralysis of the median nerve. It was noted that the Veteran had an injury to the flexor profundus tendon that might have also caused some trauma to the nerves, or that laceration of a tendon could cause nerve injuries to the underlying nerves. The examiner stated that the Veteran had loss of pincer grip; loss of sensation of the index and middle finger, and moderate impairment of the median nerve. The examiner maintained that the essential function of the Veteran's right thumb was affected due to his service-connected injury. It was noted that there was some residual disability, with about twenty percent of function of the right thumb and hand due to the injury because of the severance of the flexor profundus tendon. The examiner indicated that the only change in range of motion, as to the fingers, was in the thumb with a painful trigger finger occurring at 30 degrees of flexion. The examiner stated that other range of motion of the fingers was within normal limits. The examiner also indicated that the Veteran's right wrist disability did impact his ability to work. The examiner stated that the Veteran could lift ten pounds for one hour with his right wrist. The examiner maintained that with his right wrist condition, the Veteran could walk, sit, or stand for an unlimited period at one time or during an eight hour day. IV. Analysis The evidence demonstrates that the Veteran has right wrist arthritis with some limitation of motion. However, the current 10 percent rating is the maximum rating for limitation of wrist motion, and thus the effects of pain on use do not affect the rating under the limitation of motion code. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Additionally, the evidence shows that the Veteran's right wrist is not ankylosed (i.e. fixed or frozen in one position), and thus there is no basis for a higher rating under Diagnostic Code 5214. The Board notes that both the June 2012 and March 2015 VA wrist conditions examination reports, respectively, specifically indicated that there was no joint ankylosis, and the March 2007 VA examination also did not refer to any joint ankylosis. Further, the Board observes that x-ray reports of record do not show malunion of the radius and ulna, and clearly do not support more than a 10 percent rating under Diagnostic Codes 5211 and 5212, respectively. The evidence also fails to show nonunion of the radius and ulnar, with a flail joint, as required for a 50 percent rating under Diagnostic Code 5210. The evidence further fails to show that supination of the Veteran's right forearm is any worse than limited to 30 degrees or less, or that limitation of pronation is lost beyond the last quarter of arc and the hand does not approach full pronation as required for a higher 20 percent rating under Diagnostic Code 5213. Therefore, the Veteran is clearly not entitled to a rating in excess of 10 percent under the diagnostic codes discussed above. The Board notes, however, that the March 2015 examiner specifically referred to neurological impairment as a result of the Veteran's right wrist disability. The examiner indicated that the Veteran had mild paralysis of the median nerve. The examiner also stated that the Veteran had an injury to the flexor profundus tendon that might have also caused some trauma to the nerves, or that laceration of a tendon could cause nerve injuries to the underlying nerves. The examiner further remarked that the Veteran had loss of pincer grip; loss of sensation of the index and middle finger; and moderate impairment of the median nerve. The Board observes that it is unclear from the examiner's statements whether the Veteran actually has mild incomplete paralysis or moderate incomplete paralysis of the median nerve. The Board finds that since the examiner indicated that the Veteran had "moderate" impairment of the median nerve, that the medical evidence supports a 30 percent rating for moderate incomplete paralysis of the median nerve in the major extremity under 38 C.F.R. § 4.124a, Diagnostic Code 8515 when reasonable doubt is resolved in the Veteran's favor. The Board also observes that the prior June 2012 VA examination report noted that the Veteran had decreased sensation of the index, middle, and on the radial side of the ring finger. Therefore, the Veteran clearly has been noted to have some nerve impairment due to his right wrist disability during the period of this appeal. The Board finds that a separate initial 30 percent rating is therefore warranted for the neurologic manifestations of the right wrist disability. The Board observes that the evidence clearly does not show that the Veteran has severe incomplete paralysis of the median nerve in the major extremity as required for an even higher 50 percent rating under Diagnostic Code 8515. The March 2015 VA wrist conditions examination report solely refers to mild or moderate incomplete paralysis of the median nerve, and the prior June 2012 VA examination report, as well as the May 2007 VA examination report, respectively, do not show any such severe symptomatology. The Board finds no evidence of organic changes, such as muscle atrophy or trophic changes, which would warrant a higher rating or demonstrate more than a moderate degree of incomplete paralysis of the median nerve. The Board concludes that the evidence does not demonstrate that the Veteran's neuropathy of the right wrist approximates severe incomplete neuritis, or neuralgia, such that a rating in excess of 30 percent would be warranted under Diagnostic Codes 8615 or 8715. Accordingly, the Board finds that the Veteran's neuropathy of the right wrist at most approximates moderate incomplete neuritis, or neuralgia of the median nerve, as contemplated by these diagnostic codes. 38 C.F.R. § 4.124a, Diagnostic Codes 8615, 8715. The Board observes, as discussed above, that the provisions of 38 C.F.R. §§ 4.71a, 4.115b, Diagnostic Code 5003, 5010, 5210, 5211, 5212, 5213, 5214, and 5215, clearly do not permit a rating greater than a 30 percent rating as provided under 38 C.F.R. § 4.124a, Diagnostic Code 8515. Additionally, the VA examiner, pursuant to the March 2015 VA examination report indicated that the only change in range of motion, as to the fingers, was in the thumb with a painful trigger finger occurring at 30 degrees of flexion. The examiner stated that other range of motion of the fingers was within normal limits. Therefore, the Veteran would not be entitled to a rating in excess of 30 percent based on impaired finger movements. As this is an initial rating case, consideration has been given to "staged ratings" (different percentage ratings for different periods of time, since the effective date of service connection, based on the facts found). Fenderson, 12 Vet. App. at 119. The Board notes, however, that staged ratings are not indicated in the present case, as the Board finds that the Veteran's right wrist disability has continually been 30 percent disabling since March 15, 2007, when service connection became effective. Thus, a higher initial rating to 30 percent, and no more, continuously since March 15, 2007, is granted. The benefit of the doubt doctrine has been applied in making this decision. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, the evidence shows that the Veteran's service-connected right wrist disability results in pain, weakness, loss of strength, as well as limitation of motion and function of the right wrist. The Veteran has also been noted to have decreased sensation in his fingers of the right hand. The rating criteria considered in this case reasonably describe the Veteran's disability level and these symptoms. The Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation for the service-connected right wrist disability is adequate, and referral for extraschedular consideration is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1) (2015). ORDER An initial rating in excess of 10 percent for the orthopedic manifestations of the right wrist disability is denied. A separate initial rating of 30 percent, but no higher, is granted for a right wrist disability continuously since the effective date of service connection on March 15, 2007, subject to the laws and regulations governing the payment of monetary awards. REMAND The remaining issue on appeal is entitlement to a compensable rating for bilateral hearing loss. This case was previously remanded by the Board in November 2014, partly to obtain a copy of the November 2008 VA comprehensive hearing evaluation that included speech reception thresholds, air/bone conduction thresholds, and word recognition, that was referred to in a November 2008 VA audiological consultation report. The Board specifically noted that a November 2008 VA audiological consultation report, of record, noted that the Veteran was seen for hearing loss and ringing in both of his ears. The examiner reported that the Veteran's history was taken and that he underwent an ear canal inspection. The examiner also stated that the Veteran underwent a comprehensive hearing evaluation that included speech reception thresholds, air/bone conduction thresholds, and word recognition. The assessment was normal hearing from 250-2000 Hertz, with moderately-severe to severe sensorineural hearing loss from 3000 to 8000 Hertz, in the right ear, and normal hearing from 250 to 2000 Hertz, with severe to moderate sensorineural hearing loss from 3000 to 8000 Hertz in the left ear. Although the examiner indicated that the Veteran underwent comprehensive hearing evaluation that included speech reception thresholds, air/bone conduction thresholds, and word recognition, the actual results of that evaluation were not of record. Pursuant to the November 2014 Board remand, in January 2015, the RO requested a copy of the November 2008 VA audiological comprehensive hearing evaluation. The Board observes, however, that the only November 2008 reports that were obtained were already of record at the time of the November 2014 Board remand. The actual November 2008 audiogram with the speech reception thresholds, air/bone conduction thresholds, and word recognition, etc., was not obtained. In January 2015, the RO notified the Veteran that a copy of the complete hearing examination in November 2008 had been requested. However, the Veteran was not notified that such report was never obtained. See 38 C.F.R. § 3.159(e). As the actual comprehensive hearing evaluation results are pertinent to the Veteran's claim for a compensable rating for bilateral hearing loss, such report should be obtained. 38 C.F.R. § 3.159(c)(2) (2014); Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Additionally, a remand by the Board confers upon a Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As the development requested pursuant to the November 2014 Board remand has not been accomplished, the Board finds it necessary to remand this claim again. Accordingly, this issue is REMANDED for the following actions: 1. Obtain a copy of the November 2008 VA comprehensive hearing evaluation that included speech reception thresholds, air/bone conduction thresholds, and word recognition, (i.e., the actual audiogram), that was referred to in the November 2008 VA audiological consultation report. If any such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Finally, readjudicate the issue remaining on appeal. If the benefit sought remains denied, issue a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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 2014). ______________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs