Citation Nr: 1636426 Decision Date: 09/16/16 Archive Date: 09/27/16 DOCKET NO. 09-08 297 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for injury to the median, ulnar, and antebrachial nerves (lower radicular group), left forearm. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The Veteran served on active duty from October 1992 to July 1997. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that granted service connection for a residual scar, status post left elbow injury (claim as left forearm condition), and assigned a noncompensable evaluation. In October 2010, the Veteran appeared at a hearing held at the RO before the undersigned (i.e., Travel Board hearing). In a decision dated in March 2013, the Board granted a separate 10 percent evaluation for left forearm crush injury residuals to Muscle Group V; a separate 10 percent evaluation for left forearm crush injury residuals to Muscle Group VII; and a 30 percent evaluation for left forearm nerve injury to the median, ulnar, and antebrachial nerves (lower radicular group) of the left forearm. The Veteran then appealed to the U.S. Court of Appeals for Veterans Claims (Court). In a February 2014 joint motion for remand (JMR) filed with the Court, the parties (the Veteran and the VA Secretary) requested that the Board decision be vacated and remanded, insofar as it denied an initial rating in excess of 30 percent for peripheral neuropathy of the left upper extremity; a February 2014 Court order granted the joint motion. In a decision dated in June 2014, the Board denied the appeal. The Veteran again appealed to the U.S. Court of Appeals for Veterans Claims (Court). In an August 2015 JMR to the Court, the parties requested that the June 2014 Board decision be vacated and remanded; a Court order subsequently granted the JMR. The Board remanded the appeal in December 2015. FINDING OF FACT The injury to the median, ulnar, and antebrachial nerves (lower radicular group) of the Veteran's left forearm results in moderate incomplete paralysis. CONCLUSION OF LAW The criteria for an evaluation in excess of 30 percent for injury to the median, ulnar, and antebrachial nerves (lower radicular group), left forearm, are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Code 8512 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist 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 or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). The duty to notify has been met. See October 2010 Travel Board Hearing transcript. In this regard, VA is not required to provide notice of the information and evidence necessary to substantiate a claim upon receipt of a notice of disagreement with the rating assigned by a RO for an initial compensation award. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Neither the Veteran, nor his representative, has alleged prejudice with regard to notice. The Federal Court of Appeals has held that "absent extraordinary circumstances...it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...." See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In light of the foregoing, nothing more is required. VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2015). The RO associated the Veteran's service treatment records and VA outpatient treatment records with the claims files. No outstanding evidence has been identified that has not otherwise been obtained and associated with the record. The Board Remanded the appeal in 2015 to obtain a more complete VA examination. The February 2016 VA examination report and April 2016 opinion are thorough, address the questions posed in the remand, and are adequate upon which to base a decision with regard to the Veteran's increased rating claim. Although the examiner did not identify himself as a neurologist in the reports, the Board was able to ascertain, through internet research, that the physician is a neurologist, as had been specified in the remand. Moreover, no notice or assistance errors were raised in the August 2015 JMR. No request for or indication of a need for further evidentiary development was expressed in either the JMR, or the informal hearing presentation to the Board by the Veteran's representative in August 2016. The Veteran has not contended, nor does the evidence suggest, that the condition has worsened since the last examination. In view of the above, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Nerve injury evaluation The June 2014 Board decision was vacated pursuant to a JMR, because the parties found that the Board made an "inconsistent assessment" of symptomatology involving the Veteran's claim of occasional contracture of the left hand. The JMR noted that in the March 2013 decision, the Board found that the Veteran's "testimony that, on occasion, he must use his other hand to manually release the left hand from a position of flexion," was "encompassed within the criteria for mild paralysis." In the June 2014 Board decision, the Board stated that "the symptom is more appropriately considered as part of the muscle injury." Although the Board went on to discuss the matter with the alternative of considering the symptomatology as part of the nerve disability, the JMR found the statement that it was "more appropriately considered as part of the muscle injury" to be inconsistent with the March 2013 discussion of the symptomatology as part of the nerve disability. The JMR stated that this was "contrary to the governing authority on the precedential effect of Board decisions." In support, the JMR cited to 38 C.F.R. § 20.1303, which provides that "previously issued Board decisions will be considered binding only with regard to the specific case decided," and to Hazan v. Gober, 10 Vet. App. 511 (1997), which, in reference to an earlier, final Board decision, held that "the Board was collaterally estopped from viewing that evidence any differently from the way it had in 1990, absent a finding that the Board had committed obvious error in its 1990 decision." Id. at 521. However, an essential distinction between that and the instant case is that Hazan involved a prior final Board decision, whereas in this case, the prior Board decision has been vacated, as to the issue on appeal. The October 2013 JMR specifically vacated the portion of the March 2013 Board decision that denied entitlement to an initial separate rating in excess of 30 percent for peripheral neuropathy of the left upper extremity. Only the findings pertaining to the separate 10 percent ratings assigned under muscle groups V and VII were left undisturbed. Thus, the March 2013 Board decision is of no legal force as it pertained to the issue on appeal, and, in particular, is no longer a decision of the Board. Indeed, particularly in this case, where no further evidentiary development was specifically ordered, there would be no point to the JMR if the Board were not permitted to view evidence differently from the prior vacated decision, as the Veteran could not possibly prevail unless the evidence was viewed differently. Consideration of the appeal will move forward with this analysis in mind. Background In December 1993, during his military service, the Veteran sustained injury to his left forearm when a tire flew off a rim and crushed his left forearm in a tire cage. After the initial injury, the Veteran was noted to have decreased grip strength, decreased motion of the left wrist, and pain on use and motion of the left forearm. The service treatment records show that the Veteran's left forearm was treated for several months following the injury. No separation examination is of record. The Veteran sought service connection for residuals of the left forearm injury, among other disorders, in January 2007. The examiner who conducted February 2008 physical examination stated that the Veteran did not have pain with use of the left forearm, which was identified as being his non-dominant extremity, but did have weakness of the left extensors, as compared to the right side. There was giving way if the Veteran attempted to lift a heavy weight. In his May 2008 notice of disagreement, the Veteran reported that use of the left arm for driving, sweeping, or mopping the floor would cause tingling in the forearm down to the fingers and numbness. With physical activities, there was pain and sometimes loss of grip in the left arm. VA treatment records dated from February 2009 to July 2010 do not show any left upper extremity complaints. Neurological findings were noted to be non-focal. In July 2009, concerning the neurological system, the Veteran denied decreased sensation or strength, swelling, pain, and decreased range of motion in the extremities. On examination, sensations were grossly intact, and motor examination was 5/5 in both upper extremities. In July 2010, it was noted that there were no neurological deficits. At his October 2010 hearing before the Board, the Veteran testified that he had pain with touch to the scars on his muscles and had pain in the left forearm without touch at times. He said that, on occasion, he must use his other hand to manually release the left hand from a position of flexion. In November 2010, the Veteran was seen by a VA internist, stating that he had been told at his hearing that he needed a neurology evaluation for his forearm complaints. He complained of chronic left arm pain and associated hand/finger paresthesias since trauma to the region in 1994. He also reported intermittent contractures of all his fingers of the left hand. On examination, Tinel's sign was negative, and there were no gross motor or sensory deficits. The assessment was chronic left hand paresthesias and forearm pain, likely related to trauma. He was to be referred for formal neurological evaluation and nerve conduction tests. Accordingly, a neurology consult was provided in November 2010. The Veteran complained of distal left upper extremity pain. He said he had constant low level burning pain in the fingers. He also had daily paroxysmal twitching in various fingers of the left hand. He felt he was still slightly weak in the left upper extremity. He noted weakness as fatigability on weightlifting. On neurological examination, motor examination showed some tremoring of the left fourth finger during examination. The medial surface of the left forearm had scars, but no atrophy. Bulk was normal and there was no spasticity or rigidity in tone. Strength 5/5 in the left upper extremity. Deep tendon reflexes were 2+ in the upper extremities. On sensory examination, light touch was intact. Pinprick was decreased on the posterior aspect of the left forearm and entire left hand. Temperature and vibration sense were normal. The assessment was peripheral neuropathy secondary to mechanical injury. Electromyogram (EMG) and nerve conduction studies (NCS) were conducted in December 2010, and in a February 2011 follow-up note, it was reported that the studies had been normal. VA examinations were conducted in April 2011. On the examination of the peripheral nerves, the Veteran described his symptoms as consisting of tremors and paresthesias (consisting of numbness, tingling and pain) in the left fingers. On examination, reflexes were normal. Sensory examination of the left upper extremity revealed normal vibration, pain/pinprick, and position sense testing. Light touch was decreased in the left arm and palmar hand. The nerves affected were noted to be the medial and lateral antebrachial, median, and ulnar nerves. The examination included a detailed motor examination, and noted that the scale was from 1 to 5, with 0 reflecting total paralysis; 1 for palpable or visible contraction; 2 for active movement gravity eliminated; 3 for active against gravity; 4 for active movement against some resistance; and 5 for active movement against resistance. In the left upper extremity, elbow flexion, elbow extension, wrist flexion, wrist extension, finger flexion, finger abduction, and thumb opposition were all 5/5. The examiner reported a slight decrease in strength, to 4+/5, in the left hand grip, long finger flexion, and left wrist dorsiflexion. Muscle tone was normal. There was muscle atrophy with the left mid forearm circumference 30 cm as compared to 31 cm on the right. The examiner reviewed the December 2010 EMG/NCS test results, commenting that the impression had been normal test results of the left upper extremity. The diagnosis was status post-acute compartment syndrome of the left upper extremity secondary to mechanical injury with residual neuropathic symptoms. This was manifested by neuropathy of the left arm, with nerve dysfunction, neuritis and neuralgia, but without paralysis. The Veteran was employed full-time as a truck driver, and the effects on occupational activities were problems with lifting and carrying, and pain. Regarding the usual daily activities, there were mild effects on chores, and moderate effects on exercise, sports, and recreation. On VA examination of the muscles in April 2011, the Veteran stated that since the tire blast injury to his left forearm, the muscles cramped and went into spasm more easily with activity, causing temporary loss and pain until the cramps/spasms resolved. He stated that when this happened, he grabbed his left hand and forced dorsiflexion to stretch out the forearm muscles. He stated he had to do this for a few minutes to get the cramps resolved. VA outpatient treatment records dated from April 2011 to April 2016 show that in May 2011, chronic left arm pain was noted. Chronic forearm pain was noted in November 2011 and February 2012. Regarding the neurological system, in April 2014, he had no numbness. In November 2014, he denied numbness and tingling. In January 2015, it was noted that he had no paralysis, weakness or numbness. Otherwise, there were few if any neurological complaints regarding the left upper extremity, and abnormal findings were not noted in the treatment records. On a VA examination of the peripheral nerves performed in February 2016 by a neurologist (according to internet research), the Veteran had injury to the left ulnar and median nerve, the lateral antebrachial cutaneous nerve, and the medial brachial cutaneous nerve. The Veteran reported that in 1994 he suffered a left forearm injury while repairing a truck, when a metal lock ring propelled from a wheel tire, and hit his left forearm, also causing his left forearm to hit the tire cage, sustaining a secondary trauma. He stated that since then, he had developed distal left extremity progressive pain, pin and needles sensation and weakness. He reported mild constant pain, moderate paresthesias and/or dysesthesias, and moderate numbness in the left upper extremity. On muscle strength testing of the left upper extremity, wrist flexion, grip, and pinch strength were 4/5; elbow flexion and extension and wrist extension were 5/5. Corresponding findings on the right side were all normal at 5/5. The Veteran had muscle atrophy on the forearm, which measured 2 cm less than the right forearm. Deep tendon reflexes were normal. Sensory examination was decreased in the inner/outer forearm, hand/fingers on the left, compared to normal on the right. There were no trophic changes. Phalen's sign and Tinel's sign, noted to be tests for the median nerve, were negative. Regarding the severity, there was moderate incomplete paralysis of the left median and ulnar nerves, and the left lower radicular group. The left radial, musculocutaneous, and circumflex nerves were normal, as were the upper and middle radicular groups. Corresponding findings on the right were normal. Functional impairment of the left upper extremity, including "grasping, manipulation, etc.," was not so diminished that amputation with prosthesis would equally serve the Veteran. A summary of the physical examination noted that wrist flexion and hand abduction (median nerve), strength was 4/5. Flexion at distal interphalangeal (DIP) joints, digits 2-3 (median nerve) strength was 4/5. Thumb opposition (medial nerve) strength was 4/5. Finger abduction (ulnar nerve) strength was 4/5. Left upper extremity tone was normal. Muscle bulk was noted to show focal left dorsal forearm muscle atrophy, located 3 cm below the elbow, measuring 6 cm x 4 cm; focal left anterior forearm muscle atrophy, located 3 cm below the elbow, 4 cm x 4 cm, right hand circumference 25 cm, compared to 23 cm on the left. Sensory examination showed decreased pinprick, light touch and temperature sensation in the left lateral antebrachial cutaneous, medial brachial cutaneous, medial, and ulnar nerves. The impact on the Veteran's ability to work was moderate, with difficulties with activities such as pushing, pulling, twisting, lifting, typing, doing laundry, using the left hand, due to left arm pain and left hand weakness. In April 2016, the examiner provided an opinion. He summarized relevant clinical findings, noting that physical examination had shown motor (strength) of 4/5 for left wrist flexion and hand abduction; flexion at distal interphalangeal joints, digits 2-3; and left thumb opposition-thumb to index finger, all of which were noted to involve the median nerve. Left grip, noted to involve the median and ulnar nerves, was 4/5. Strength was 4/5 for left wrist flexion and left finger abduction, both involving the ulnar nerve. Otherwise, strength was 5/5. The summary also included muscle findings. Tone was normal in all muscle groups. As to bulk, there was atrophy in the forearm, 3 cm distal to the elbow, measuring 31.5 cm on the left, as compared to 33.5 cm on the right. There was also focal left dorsal forearm muscle atrophy and focal left anterior forearm muscle atrophy, and the left hand circumference measurement (3 cm distal to the wrist) was 23 cm, as compared to 25 cm on the right. Additionally, reflexes were all normal. Sensory examination revealed decreased sensation in the left inner forearm, noted to implicate the medial antebrachial cutaneous nerve, and the outer forearm (lateral antebrachial cutaneous nerve). There was also decreased sensation along the median nerve, affecting the thumb, index and lateral palmar area, and the ulnar nerve, in the medial palmar area. Otherwise, sensation was normal. There were no autonomic or trophic changes noted. The examiner also addressed the Veteran's testimony that on occasion, his left hand becomes fixed in flexion, and he must use his right hand to manually release the left hand from the position of flexion. The examiner noted that the Veteran reported that approximately 3 months prior his evaluation he experienced one episode in which his left hand was spontaneously fixed in flexion, and he used his right hand to manually release the left hand from position of flexion. The examiner commented that there was no documentation of the left hand fixed in flexed position, including in service treatment records, VA treatment records, and the examinations. The Veteran's reported flexed left hand phenomenon was reliant on the Veteran's description. There was no objective evidence in medical literature to apply to such circumstances to predict limitations, report manifestation of the condition or identify the cause, and would rely on mere speculation by the examiner. The examiner went on to explain that flexion of the hand was mediated by the ulnar and median nerves, and the flexor carpi ulnaris, flexor carpi radialis, and palmaris longus muscles. A hand fixed in flexion was a phenomenon that would require an involuntary contraction, spasticity or/and hypertonia of the wrist flexors muscles (listed above) during the event. However, peripheral nerves injuries were not characterized by hypertonia or spasticity, or intermittent flexion or extension of the joints. No left hand fixed in flexion episode was noted during his evaluation, and no hypertonia or spasticity of the wrist flexor was present. No abnormal activation of the left wrist flexor muscles was elicited by percussion. The examiner emphasized that the reported flexed hand episode was not supported by any objective findings. He added there was nothing in the medical literature to establish that a median and ulnar nerve injury causes intermittent flexion of the hand or spastic episodes of flexed hand. Put another way, there was simply no medical basis why the flexed episode would occur. The examiner concluded that peripheral nerves injuries were characterized by weakness, atrophy and flaccid muscles. Lateral antebrachial cutaneous nerve provided sensory innervation to lateral aspect of forearm. The medial antebrachial cutaneous nerve innervated the skin of anterior and medial surfaces of forearm as far as the wrist. The Veteran had injury of the left median, ulnar and lateral and medial antebrachial cutaneous nerves at the forearm. The reported flexed hand symptom, as reported by the patient was not characteristic of peripheral nerve injury. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155. If two evaluations are potentially applicable, the higher evaluation 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 When, as here, the Veteran is requesting a higher rating following an initial grant of service connection, "staged" ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). For impairment of an upper extremity, the disability rating assigned depends on whether the extremity is the major extremity or the minor extremity. The major extremity is the one predominantly used. 38 C.F.R. § 4.69. It is not disputed that the Veteran is right-handed, i.e., that the right upper extremity is his dominant, or "major" extremity, while the left upper extremity is the "minor" extremity. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Neurological disabilities of the upper extremities manifested by incomplete or complete paralysis are rated under the schedular criteria of 38 C.F.R. § 4.124a, DCs 8510 to 8519. The VA examinations have shown abnormal findings involving the median nerve, the ulnar nerve, the lower radicular group, and the musculocutaneous nerve. Disability of these nerves is evaluated under DCs 8512, 8515, 8516, and 8517. 38 C.F.R. § 4.124a. Neuritis and neuralgia of these nerves are evaluated under DCs 8612, 8615, 8616, 8617, 8712, 8715, 8717, and 8717. 38 C.F.R. § 4.123, 4.124. DC 8510, concerns impairment of the upper radicular group (the fifth and sixth cervicals); DC 8511 concerns impairment of the middle radicular group; DC 8512 concerns impairment of the lower radicular group; DC 8513 concerns impairment of all radicular groups. DC 8515 concerns the median nerve; DC 8516 concerns the ulnar nerve; DC 8517 addresses impairment of the musculocutaneous nerve. Under DC 8512, a 20 percent disability rating is warranted when there is mild incomplete paralysis of the lower radicular group in the minor or major hand. A 30 percent is appropriate when there is moderate incomplete paralysis of the minor hand. A 40 percent is appropriate when there is severe incomplete paralysis of the lower radicular group of the minor extremity. When there is complete paralysis of the lower radicular group, involving all intrinsic muscles of the hand, and some or all flexors of the wrist and fingers, wherein the paralysis results in the substantial loss of use of the minor hand, the maximum 60 percent disability rating is awarded. 38 C.F.R. § 4.124a, DC 8512. Under DC 8515, a 10 percent rating is warranted for mild incomplete paralysis of the median nerve of the non-dominant upper extremity. A 20 percent rating is warranted for moderate incomplete paralysis of the minor extremity. A 40 percent rating requires severe incomplete paralysis of the median nerve in the minor extremity. Complete paralysis warrants a 60 percent rating. 38 C.F.R. § 4.124a. Under DC 8516, complete paralysis of the ulnar nerve includes the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. For incomplete paralysis, a 10 percent rating is assigned for a mild disability on the non-dominant arm, a 20 percent rating is assigned for a "moderate" disability afflicting the non-dominant hand, and a 30 percent rating is assigned for "severe" disability afflicting the non-dominant hand. 38 C.F.R. § 4.124a. Under DC 8517, moderate incomplete paralysis of the musculocutaneous nerve warrants a 10 percent evaluation for both the major and minor extremities. Severe incomplete paralysis of the musculocutaneous nerve warrants a 20 percent evaluation for both the major and minor extremities. Combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note following Diagnostic Code 8719. Accordingly, the most appropriate Diagnostic Code for the combined nerve injuries is that pertaining to the nerves of the lower radicular group, which involve the function of all intrinsic muscles of the hand, and some or all of the flexors of the wrist and fingers. 38 C.F.R. § 4.124a, Diagnostic Codes 8512 (paralysis), 8612 (neuritis), and 8712 (neuralgia). In this regard, the lower radicular group provides for higher ratings than any of the other potentially applicable diagnostic codes. On the VA neurology clinic evaluation in November 2010, motor examination showed some tremoring of the left fourth finger during examination. Strength was 5/5 in the left upper extremity. At this time, on sensory examination, light touch was intact, but pinprick was decreased on the posterior aspect of the left forearm and entire left hand. However, EMG and NCS conducted in December 2010 were normal. On the VA examination in April 2011, the Veteran described his symptoms as consisting of tremors and paresthesias (consisting of numbness, tingling and pain) in the left fingers. On examination, reflexes were normal. Sensory examination of the left upper extremity was entirely normal, except for decreased light touch in the left arm and palmar hand. Likewise, motor examination revealed full strength except for a slight decrease in strength, to 4+/5, in the left hand grip, long finger flexion, and left wrist dorsiflexion. The examiner concluded that his neuropathy was manifested by nerve dysfunction, neuritis and neuralgia, but without paralysis. The VA examination in February 2016 resulted in an impression of moderate incomplete paralysis of the left median and ulnar nerves, and the left lower radicular group. The impact on the Veteran's ability to work, due to the peripheral nerve disabilities, was moderate, with difficulties with activities such as pushing, pulling, twisting, lifting, typing, doing laundry, using the left hand, due to left arm pain and left hand weakness. Moreover, the electrodiagnostic studies in 2010 were entirely normal. VA treatment records dated throughout the pendency of the claim, although showing regular treatment for other conditions, show infrequent complaints of chronic left forearm pain, and few if any neurological abnormalities. The Veteran contends that his disability warrants a higher rating, but the medical evidence of record does not show disability to be more than moderate. The medical examinations included the Veteran's subjective statements of his manifestations, and the most recent examination in particular contained a description of his limitations. The Veteran has been observed to have a tremor involving the left hand, as well as slightly decreased strength in left hand grip, long finger flexion, and left wrist dorsiflexion. He states that he has paroxysmal twitching, and a constant low-level burning pain. On one examination he had decreased light touch in the left arm and palmar hand, whereas the other revealed pinprick to be decreased on the posterior aspect of the left forearm and entire left hand, and electrodiagnostic tests were normal. The most recent examination disclosed atrophy in the forearm and hand, but strength was no more than mildly decreased. There was decreased sensation, but reflexes were normal, and there were no trophic changes. Significantly, the totality of the symptoms have been none to mild in degree, but when considering all positive symptoms shown on different occasions, as well as the Veteran's testimony, moderate impairment is suggested. Regarding the Veteran's contention that on occasion, his left hand becomes fixed in flexion, and he must use his right hand to manually release the left hand from the position of flexion, the opinion from the VA examiner in April 2016, detailed above, concluded that the reported flexed hand symptom, as reported by the Veteran, was not characteristic of peripheral nerve injury. The explanation also indicated that because this phenomenon had never been observed by a medical professional, and medical literature did not provide an explanation, no cause or limitations could be specified. The examiner also commented that the Veteran reported having only one such episode in the past 3 months. There is no medical evidence to the contrary, and the Board finds that based on these factors, the Veteran's reported symptom of occasional fixed flexion of his hand, necessitating manual release, is not characteristic of peripheral nerve injury. Nevertheless, even if assumed to be associated the service-connected left upper extremity peripheral nerve injury, the condition has not been present with such frequency or duration as to warrant a higher rating. In the previous JMR, the parties contended that "[a]lthough wholly sensory impairment is rated at most moderate in nature under the rating schedule, Appellant's symptomatology suggests more than sensory impairment." This seems to argue that because wholly sensory impairment cannot be rated more than moderate, therefore, moderate impairment must consist only of sensory impairment. This is a logical fallacy, however. Instead, the provision is a limitation on the rating to be assigned for wholly sensory impairment, versus impairment with organic changes, not a definition of the criteria for a rating based on mild and moderate impairment. See 38 C.F.R. §§ 4.123, 4.124. Incomplete paralysis, neuritis, and neuralgia are all based on the same criteria of mild, moderate, or severe (for the Diagnostic Codes potentially applicable in this case) impairment, except that wholly sensory findings are limited to the equivalent of mild or moderate incomplete paralysis. In this regard, in the introduction of the schedule of ratings for diseases of the peripheral nerves, an explanatory paragraph clarifies that the term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. Similarly, neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is given a maximum rating of severe incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating, which may be assigned for neuritis, not characterized by organic changes referred to in this section, will be for moderate incomplete paralysis. Id. Neuralgia characterized usually by a dull and intermittent pain in the typical nerve distribution is to be rated on the same scale, with a maximum rating equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Additionally, combined nerve injuries should be rated by reference to the major involvement, or of sufficient in extent, consider radicular group ratings. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note following Diagnostic Code 8719. The most recent VA examination characterized the Veteran's overall impairment from his service-connected peripheral nerve injury to be moderate. The earlier examinations found symptoms to be even less severe, and treatment records show few complaints and even fewer abnormal findings. Given the Veteran's regular treatment for a variety of disabilities, the Board does not find the paucity of complaints or abnormal findings in the treatment records to be consistent with severe incomplete paralysis. There is simply no evidence to support a finding of severe incomplete paralysis, including the Veteran's lay descriptions of his symptoms. For example, he testified that he had pain with touch, episodes of increased pain, and constant low-level pain. This evidence does not more closely approximate the criteria for severe impairment. The Board also notes that in addition to the 30 percent evaluation for peripheral neuropathy of the left upper extremity, the Veteran is in receipt of a 10 percent for injury to MG V, and a 10 percent rating for injury to MG VII. The combined evaluation for the left upper extremity crush injury residuals is 40 percent. 38 C.F.R. § 4.25. However, only the peripheral neuropathy rating is currently before the Board. A muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). Therefore, in assessing the peripheral neuropathy disability currently on appeal, the Board must ensure that there is no overlap of impairment of function which is already rated under the two muscle group injuries. See 38 C.F.R. § 4.14. Here, the muscle groups are MG V and VII. Muscle Group V comprises the flexor muscles of the elbow, identified as the biceps, brachialis, and brachioradialis muscles. The function of these muscles is elbow supination and flexion of the elbow. The other muscle group, MG VII, comprises the muscles arising from the internal condyle of the humerus, specifically, the flexors of the carpus, which includes the flexor carpi radialis, the long flexors of the fingers and thumb, and pronator. Their function is flexion of the wrist and fingers. The current 10 percent rating reflects a moderate disability of the dominant or non-dominant wrist and finger flexors. 38 C.F.R. § 4.73, Diagnostic Code 5307. The April 2016 examiner explained that flexion of the hand involved the ulnar and median nerves, and the flexor carpi ulnaris, flexor carpi radialis, and palmaris longus muscles. Although under these circumstances, it appears as if separate ratings for the neurological and muscle injuries, for Muscle Group VII, involve some overlap. However, because the current 30 percent rating for peripheral neuropathy contemplates moderate nerve impairment, which the examiner found to be present based on all symptomatology, it is not necessary to further address the potential pyramiding at this time, because a rating in excess of 30 percent is not warranted, with or without consideration of any potentially duplicative symptoms. In sum, for the reasons discussed above, a rating in excess of 30 percent is not warranted for the left upper extremity peripheral nerve disability. The Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. However, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The Board has considered whether the Veteran is entitled to consideration of referral for an extraschedular rating, which requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F. 3d 1366 (Fed. Cir. 2009). The first question in such consideration is whether the assigned schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptoms, then the claimant's disability picture is contemplated by the rating schedule. If the schedular evaluation is adequate, no referral is required. The initial 30 percent evaluation is assigned for peripheral neuropathy of the left upper extremity affecting three nerves. Within these schedular evaluations, the Board has considered objective findings and testimony regarding both constant pain and episodic increases in pain, mild incomplete paralysis, and neuropathy manifested by pain, paresthesias, and involuntary movement. Each complaint, symptom, or finding has been considered and is encompassed within an assigned schedular rating. Further, higher schedular evaluations are available, but the Veteran's disability does not meet the criteria for a higher rating. If a schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The schedular criteria are adequate, and that the symptoms of the Veteran's left forearm injury, including muscle, nerve, and scar residuals, are fully contemplated by the applicable rating criteria. The Veteran's disability picture is consistent with the evaluations assigned, and left forearm injury has not precluded full-time employment. Additionally, the Veteran does not contend that he would be better served by amputation of the left forearm. Based on the foregoing, referral for consideration of extraschedular evaluation for a muscle, nerve, or scar disability of the left forearm is not warranted. 38 C.F.R. § 3.321(b). Finally, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected symptoms experienced. In this case, however, there are no additional symptoms that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. ORDER An initial evaluation in excess of 30 percent for nerve injury to the median nerve, ulnar nerve, and antebrachial nerve (lower radicular group), left forearm, is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs